Approximately 1.2 million U.S. residents are currently living with HIV, with tens of thousands of new infections occurring each year. Over 90% of new infections resulted from sexual contact and could be prevented with medication. The Centers for Disease Control and Prevention (CDC) estimates that more than 360,000 people in the United States received prescriptions for pre-exposure prophylaxis (PrEP) in 2021. However, this number pales in comparison to the estimated 1.2 million individuals who would benefit from PrEP to avoid HIV infection. Given the variability of laws promoting LGBTQIA+ equality at the state level, understanding the relation between PrEP uptake by states’ residents and their political landscapes on issues affecting the queer community may explain why that gap exists.
Examining the State-Level Data
Using the Human Rights Campaign’s 2022 State Equality Index as a uniform rating metric, I assigned a grading scale to the LGBTQIA+ friendliness of each jurisdiction based on the number of LGBTQIA+ legal protections codified by each state. These factors include anti-discrimination protections for employment, housing, and gender-affirming care, among others. The higher the score, the friendlier the state’s legal climate for LGBTQIA+ residents. The CDC also generates data on PrEP coverage in the U.S., which shows the percentages of people who would likely benefit from PrEP usage in each state compared to actual usage in that same state. By comparing the percent utilization metric against the LGBTQIA+ friendliness metric, the data (sorted from lowest to highest LGBTQIA+ score) can show relevant trends between the LGBTQIA+ state law protections in each jurisdiction and correlations in PrEP uptake.
In performing this analysis, we examined whether there is a correlation between jurisdictions that could be described as “friendlier” to LGBTQIA+ communities and PrEP utilization. However, the data does not support this specific hypothesis. The states with the lowest percentage of PrEP usage (less than 20% coverage) are in the bottom 60% of states in terms of LGBTQIA+ score. However, the distribution of these states on the LGBTQIA+ friendliness scale does not necessarily correlate with lower PrEP usage. Meanwhile, those states with the highest PrEP usage (35% or greater) are dispersed randomly across the U.S. regardless of LGBTQIA+ state law protections, with a small cluster of states (Vermont, Rhode Island, New York, Nevada, and the District of Columbia) being in the top ten in terms of both PrEP usage and LGBTQIA+ scorecard results.
While the data does not meet the hypothesized result, it does demonstrate to policymakers where improvements need to be made to increase PrEP uptake. Furthermore, a more randomized data set shows that all jurisdictions can do more to reach additional communities through targeted actions to increase knowledge about and uptake of PrEP for at-risk individuals.
What States Can Do
Given the varied usage across states, public health officials must do more to achieve the CDC’s goal of 50% PrEP usage by 2025. In August 2023, the U.S. Preventive Services Task Force (USPSTF) released a recommendation on the use of the long-acting injectable (LAI) form of PrEP, known as Apretude. With this recommendation, states will be required by law to cover LAI prophylaxis by 2025, building upon coverage requirements for oral PrEP from a 2019 USPSTF recommendation.
However, this recommendation alone is not enough. Public health officials must continue to reduce barriers to accessing PrEP — financial or otherwise. For example, in a CDC study regarding PrEP uptake, 4 in 10 transgender women reported PrEP usage. These low rates of uptake can be partly attributed to economic factors, such as decreased access to employment and housing, and societal factors, such as stigma. To reduce the impacts of these factors, states should codify anti-discrimination laws in the areas that make up the LGBTQIA+ friendliness grading, creating positive impacts across marginalized populations. Ancillary services, community engagement, and reduction of barriers to access are critical components of a delivery system that encourages usage and reduces barriers to continued usage — all of which align with the CDC’s goals for PrEP uptake.
Most importantly, equity must remain a focus of these services. Data from 2019–2022 suggests that while PrEP prescriptions for white-identifying individuals who could benefit from them are approaching 100% coverage, Black and Hispanic populations saw no more than 25% coverage.
Recently, physicians, legislators, and a research team at Yale University developed a mobile pharmacy — an initiative that reduces barriers to access. This model could be an example for other jurisdictions to increase access to prophylaxis and other vital treatments. State and local regulators must, however, ensure adequate legal landscapes exist to enable advances in delivery to impacted communities. These measures include regulations around licensure for medical facilities, zoning of where services can be delivered, and scope of practice for providers delivering harm reduction services.
Looking Ahead
Some states have already engaged in policymaking to make their jurisdictions friendlier to LGBTQIA+ populations and facilitate access to PrEP for impacted communities. Despite that progress, many others have not. As the number of HIV cases in the U.S. continues to increase, increasing the uptake of preventative measures is vital — especially for the communities most impacted. The evidence shows that states must continue prioritizing policies that reduce barriers to and destigmatize PrEP uptake.
Perhaps the Yale mobile pharmacy can serve as a model for future interventions seeking to deliver services to underserved populations and communities — moving the needle on PrEP coverage closer to universal protection for those who would benefit most.
