Study Flags Gaps in PrEP Use Among Youth at Risk for HIV

U.S. adolescents and young adults at risk of HIV aren’t getting the preexposure prophylaxis (PrEP) prescriptions they need, according to a national analysis of prescription data on over 100,000 youth.

In individuals ages 13 to 21 years with a documented sexually transmitted infection (STI) or high-risk sexual behavior, just 1.6% filled a PrEP prescription from 2018 to 2022, reported researchers led by Nicholas Venturelli, MD, MPH, of Boston Children’s Hospital.

Minors, young women, and those living in the South faced larger disparities, the findings in JAMA Pediatrics showed.

“This cohort study demonstrates persistently low rates of PrEP prescription among youths in the U.S., even among groups at higher risk, such as those with a prior syphilis diagnosis,” Venturelli and colleagues wrote. “This reflects a gap in preventive HIV care for youths and underscores the need for tailored and more effective interventions to improve PrEP access and use.”

Young men were 15 times more likely than young women to fill a PrEP prescription (adjusted hazard ratio [aHR] 15.6, 95% CI 13.5-18.1), while patients ages 20 to 21 years were three times more likely than minors ages 13 to 17 years to receive PrEP (aHR 3.38, 95% CI 2.83-4.03). And relative to the Northeast, PrEP fill rates were 26% lower in the Midwest (aHR 0.74, 95% CI 0.63-0.87) and 31% lower in the South (aHR 0.69, 95% CI 0.60-0.80).

The PrEP gap between young men and women is “critical,” the researchers noted, given that women accounted for 18% of all new HIV diagnoses in 2021. The perception that PrEP is primarily a tool for men who have sex with men may widen that gap and add to young women’s longer time between identification and PrEP initiation.

In a viewpoint that published at the same time, Maria Trent, MD, MPH, of Johns Hopkins University in Baltimore, and colleagues noted that in 2022, only 3% of those in the U.S. living with HIV were adolescents and young adults ages 13 to 24 years — but that age group accounted for 19% of that year’s new HIV diagnoses. Their disproportionate share of new infections “sustains HIV incidence as they age into older populations.”

Given that, younger people “represent a critical inflection point” in the nation’s HIV epidemic, the viewpoint authors wrote. “Yet existing systems continue to rely on adult-centered models that inadequately address the structural, policy, and developmental contexts shaping youth engagement.”

If HIV prevention and intervention approaches aren’t tailored to young people, “recent epidemiological gains risk stagnation or reversal,” Trent and colleagues noted. “Integrating HIV services with housing support, behavioral healthcare, and transportation assistance could be shown to improve continuity of care, particularly for youth navigating multiple systems of support.”

Venturelli and fellow researchers analyzed data from January 2018 to December 2022 from the national Merative MarketScan Research Database of employer-based insurance claims. The study included youth ages 13 to 21 years with an ICD-10 code suggestive of potential benefit from PrEP, including high-risk sexual behavior or an STI such as chlamydia, gonorrhea, or syphilis.

The primary outcome was a PrEP prescription fill of emtricitabine and tenofovir disoproxil fumarate (Truvada), emtricitabine and tenofovir alafenamide (Descovy), or injectable cabotegravir (Apretude). The study dataset couldn’t capture prescriptions written but not filled, and nonadherent patients were thus classified as unexposed in the study analyses.

Among the 100,536 participants in the study, mean age was 18.8 years, 71.2% were female, 56% had an ICD-10 code for high-risk sexual behavior, 48.9% had a code for an STI, and 4.9% had both. More than one-third of the young people (34.7%) had a mental health diagnosis code, and 7.1% had substance use codes. More than half (52.4%) lived in the South, 20.5% lived in the Midwest, 15.4% in the Northeast, and 11.3% in the West.

There were 1,598 participants who filled a PrEP prescription during follow-up. Among those, 27.1% had a documented STI, while 77.9% had documented high-risk sexual behavior. Those with syphilis were three times more likely to fill a PrEP prescription (aHR 3.61, 95% CI 2.73-4.76), and those with gonorrhea were nearly twice as likely (aHR 1.97, 95% CI, 1.55-2.52) compared to participants without those conditions.

Perceived sexual behaviors, not STIs, led to most of the PrEP indications, which “highlights the importance of screening for sexual behavior, not just STIs,” Venturelli and colleagues said. But the high number of youths with bacterial STIs who didn’t get PrEP points to missed HIV prevention opportunities, they added.

Youth in states with progressive LGBTQ+ laws were 36% more likely to receive a prescription (aOR 1.36, 95% CI 1.23-1.52). Having privacy laws that allowed minors to consent to HIV care didn’t significantly shift PrEP fill rates.

Family physicians were most likely to write filled PrEP prescriptions, at 23.2%, and pediatricians wrote 4.8% of the prescriptions.

Study limitations included the dataset’s lack of information on race, ethnicity, gender identity, or sexual orientation. In addition, the method used to identify PrEP-eligible youth may have missed some youth with diagnoses that suggest HIV risk.