Associated Costs Are a Barrier to HIV Preexposure Prophylaxis Access in the United States

HIV pre-exposure prophylaxis (PrEP), a biomedical HIV prevention intervention, reduces the risk of HIV acquisition by upwards of 90% for sexual encounters and 70% for injection drug use. If widely used, PrEP has the potential to help end the HIV epidemic in the United States.1 In 2015, the Centers for Disease Control and Prevention (CDC) estimated that approximately 1.2 million people were at high risk of acquiring HIV and had a clinical indication for PrEP.2 One of the four pillars of the federal government's Ending the HIV Epidemic (EHE) initiative is increasing access to and use of PrEP; in fiscal year 2021, $386 million was appropriated for the EHE initiative, of which $102 million was allocated to provide "HIV testing, linkage to care, and prescription of PrEP."1 Additionally, an objective of the National HIV/AIDS Strategy for the United States (2022-2025) is to increase PrEP coverage to 50% from a 2017 baseline of 13.2%.3 Despite the first PrEP antiretroviral being approved by the US Food and Drug Administration in 2012, less than 20% of those at high risk of HIV received a PrEP prescription in 2019. There are inequities in PrEP uptake across communities at higher risk for HIV-Black and Hispanic communities, cisgender women, transgender women, and people living in the South-because of high brand-name medication costs and limited access to financial resources to cover costs of PrEP-associated medical visits and laboratory tests, among other factors.5 Counterintuitively, the most updated available PrEP-utilization data demonstrate that health systems and public health efforts have been less effective at reaching those most at risk for HIV. Black and Hispanic individuals are estimated to have higher rates of clinical indications for PrEP, at 43.7% and 24.7%, respectively.6 Despite this, in 2016, almost 70% of PrEP users were White, whereas only 11 % were Black and 13% were Hispanic.6 There are also disparities across gender, age, and geography. PrEP uptake among men was 14times higherthan uptake among women in 2016, and people aged 25 to 44 years were more likely to be PrEP users than people of other ages.6 The US South accounted for over half of new HIV diagnoses in 2016 but represents only 30% of all PrEP users.7 Overall, Southern states had the lowest levels of PrEP utilization relative to HIV diagnoses.