CHAPTER ONE
INTRODUCTION
1.1 Background of the Study
For over three decades since its emergence in the 1980s, HIV has been a significant concern in public health. This virus specifically targets CD4+ T cells, which are vital for the body's immune response, resulting in a weakened immune system (Douek et al., 2002). If the virus progresses, it eventually leads to acquired immunodeficiency syndrome (AIDS), making it difficult for the body to effectively defend against infections (NHS, 2017). While initially detected among men who have sex with men (MSM) in Europe and the United States, HIV has now become more prevalent in Sub-Saharan Africa, particularly among heterosexual individuals engaging in unprotected intercourse (Gilbert et al., 2007).
Since the 1980s, HIV/AIDS has impacted an estimated 79 million individuals worldwide. The virus infected around 1.5 million individuals in the year 2020 alone, marking a significant number of new cases (Sato et al., 1989). Nigeria, with a population of approximately 206,139,589 individuals as of 2020, holds the largest population in Sub-Saharan Africa. In 2018, Sub-Saharan Africa accounted for 67% of all new infections globally (World Health Organization (WHO), 2018).
On a global scale, HIV is categorized into two main types: HIV-1 and HIV-2, each consisting of different subtypes. In Nigeria, HIV-1 is the primary driver of the HIV epidemic, with subtype A being prevalent in Southern Nigeria and subtype G dominating in Northern Nigeria (Peters et al., 2000).
HIV infection leads to a compromised immune system, resulting in the occurrence of opportunistic infections. These infections further weaken the immune system, making it difficult for the body to defend against new infections (Iroezindu et al., 2013). Tuberculosis is the predominant opportunistic disease, significantly contributing to mortality rates in Nigeria among individuals with HIV, causing approximately 21 deaths per 100,000 people. The impact of the epidemic is far-reaching, affecting not just adults but also children, with an estimated 2.23 million children in Nigeria being orphaned due to HIV, as stated in the 2014 Global AIDS Response Country Progress Report (National Agency for the Control of AIDS, 2015)
Annually, there are around 2.5 million new HIV cases worldwide, and unfortunately, there is currently no cure available for this disease. Despite ongoing research efforts aimed at developing a vaccine, it will take several years before a more practical solution becomes accessible. In the absence of treatment, the majority of HIV patients will succumb to the disease within a decade (Buttram et al., 2019: Garnett et al., 2017).
However, despite the availability of treatment, achieving long-term survival comes with significant costs. Survivors are at risk of acquiring new opportunistic infections, and existing infections may reactivate, resulting in substantial morbidity. Furthermore, the use of highly active antiretroviral therapy (HAART) is accompanied by undesirable effects, potential drug interactions, and the risk of developing drug resistance. Many patients eventually experience lipid abnormalities and become susceptible to premature atherosclerosis.
Considering that the development of an HIV vaccine is still years away, a new approach has been suggested to reduce the risk of new infections in high-risk individuals. This approach involves the implementation of pre-exposure chemoprophylaxis as a means of lowering the risk. It has long been understood that the sexual transmission of the virus is strongly linked to the concentration of the virus in genital secretions and blood.
Multiple studies have provided evidence that antiretroviral drugs can be utilized to lower the transmission potential of individuals at high risk by reducing the virus concentration in their blood and genital secretions. Currently, pre-exposure chemoprophylaxis is not just a theoretical idea but a practical intervention that effectively decreases the incidence of new HIV cases (Sundareshan et al., 2022).
Pre-exposure prophylaxis (PrEP) refers to the regular use of antiretroviral therapy (ART), either on a daily basis or before and after HIV exposure events (referred to as "on-demand" or "event-driven" PrEP), to reduce the risk of contracting HIV infection (Chou et al., 2019). Several trials have demonstrated that closely monitored adherence to pre-exposure chemoprophylaxis is highly effective in significantly reducing the risk of HIV infection, nearly to zero. This innovative approach is now considered more effective in preventing HIV infection compared to post-exposure treatment.
It is important to emphasize that pre-exposure chemoprophylaxis exclusively offers protection against HIV and does not provide safeguarding against other sexually transmitted infections (STIs), hepatitis, or blood-borne infections. The key aspect of this regimen is that strict adherence to medication is crucial. Individuals who consistently miss doses of their medication are at a higher risk of acquiring HIV. Therefore, pre-exposure chemoprophylaxis for HIV prevention is part of a comprehensive package that includes support, sexual education, and guidance on the importance of adhering to the treatment regimen (Sundareshan et al., 2022).
As prescription requirements are typically associated with these medications, the management of the epidemic has increasingly become the responsibility of a healthcare system plagued by various challenges, such as a shortage of physicians.
In this scenario, pharmacists possess immense untapped potential. Pharmacies are conveniently accessible, and pharmacists are often available without the need for appointments. Since pharmacies and pharmacists are generally not associated with specific health conditions, they are considered a setting largely free from the stigma surrounding HIV.
Moreover, the availability of pharmacists to the general population, their pharmaceutical expertise, and their expanding roles in medication therapy management through collaborative practice agreements create a favorable environment for improving access to pre-exposure prophylaxis (PrEP). Hence, this study aims to explore the role of pharmacists in prescribing HIV pre-exposure prophylaxis, highlighting their potential contribution.
1.2 Statement of the Problem
While pre-exposure prophylaxis (PrEP) has demonstrated effectiveness in preventing HIV transmission, there are persistent challenges evident in its underutilization. Barriers such as limited access to healthcare providers, insufficient awareness about PrEP, stigma, and concerns regarding cost and potential side effects have impeded its widespread acceptance.
Broadening the scope of pharmacists in the provision of PrEP prescriptions has the potential to address some of these barriers and enhance the adoption of this preventive measure. Existing literature mainly focuses on qualitative studies that explore aspects such as PrEP screening, barriers to access, feasibility, accessibility through community pharmacies, and interdisciplinary collaborations. However, there is limited emphasis on the specific roles of pharmacists in the initiation and provision of PrEP. By filling this research gap, a more comprehensive understanding of the roles of pharmacists in PrEP prescription can be attained.
1.3 Aim of the Study
The aim of this study is to examine the role of pharmacists in prescribing HIV pre-exposure prophylaxis.
1.4 Objectives of the Study
The specific objectives of this study are as follows:
- To assess the current extent of pharmacist involvement in prescribing HIV pre-exposure prophylaxis.
- To examine the impact of pharmacist-prescribed PrEP on PrEP uptake and adherence.
1.5 Research Questions
- What is the current extent of pharmacist involvement in prescribing HIV pre-exposure prophylaxis?
- What is the impact of pharmacist-prescribed PrEP on PrEP uptake and adherence?
1.6 Research Hypothesis
H0: Pharmacists play a significant role in prescribing HIV pre-exposure prophylaxis.
H1: Pharmacists play a significant role in prescribing HIV pre-exposure prophylaxis.
1.7 Justification of the Study
This study is important because it explores the potential role of pharmacists in expanding access to PrEP and improving PrEP utilization. Understanding the current extent of pharmacist involvement in PrEP prescribing, their perceptions and attitudes, and the impact of their involvement on PrEP uptake and adherence can inform policy and practice to optimize PrEP delivery.
1.8 Scope of the Study
This study will focus on the role of pharmacists in prescribing HIV pre-exposure prophylaxis.
