PrEP for HIV Prevention in the U.S.
Notable gains have been made in increasing pre-exposure prophylaxis (PrEP) use for HIV prevention in the U.S. Preliminary CDC data1 show that in 2020, about 25% of the 1.2 million people for whom PrEP is recommended were prescribed it, compared to only about 3% in 2015.
The growth in PrEP use, along with increased testing and treatment has played a part in recent decreases in new HIV infections. CDC estimates new HIV infections fell 8% from 2015 to 2019 (37,800 to 34,800), after a period of general stability. The impact of COVID-19 related disruptions in HIV prevention services on these trends is not yet known.
PrEP is a key prevention strategy for ending the HIV epidemic in the U.S. One of the goals of the federal Ending the HIV Epidemic in the U.S. (EHE) initiative is by 2030 to have 50% of people who could benefit from PrEP using it.
Many longstanding social and economic factors—including transphobia, stigma, systemic racism, experiencing homelessness or unemployment, and others—have put transgender women at high risk for HIV and made it more difficult for them to access services. A recent CDC studypdf icon found that four in 10 transgender women in seven major U.S. cities have HIV. Expanding PrEP use among transgender women is key to decreasing new HIV infections in this population.
The survey showed that 32% of HIV-negative transgender women reported using PrEP, even though 92% were aware of the medication. Previous studies have also revealed high knowledge of PrEP and its benefits but very low uptake among transgender women.
Despite overall progress toward ending HIV, HIV continues to affect some groups severely and disproportionately. Rates of new HIV infections among Black/African American people (hereafter referred to as Black) are over eight times as high—and among Hispanic/Latino people almost four times as high—as that of rates of new HIV infections among White people.
To end the HIV epidemic, we need to scale up HIV testing, make sure people with HIV are linked to care and getting treatment, and ensure equitable access to HIV prevention—including PrEP for everyone who could benefit. However, current PrEP coverage remains uneven across racial and ethnic groups, age groups, and for transgender persons.
Black and Hispanic/Latino people account for the majority of people for whom PrEP is recommended, but have the lowest rates of PrEP use among all racial/ethnic groups. Preliminary CDC data show only 9% (42,372) of the nearly 469,000 Black people who could benefit from PrEP received a prescription in 2020, and only 16% (48,838) of the nearly 313,000 Hispanic/Latino people who could benefit from PrEP received a prescription.2
Young people ages 16-24 are the least likely to be using PrEP. Preliminary CDC data show only about 16% (38,454) of this population for whom PrEP is recommended were prescribed it in 2020, compared to the approximate 27% (119,246) and 30% (72,146) of people aged 25-34 and 35-44, respectively.
PrEP coverage is also unevenly distributed among people based on sex. Among people for whom PrEP is recommended, PrEP coverage was about three times as high in 2020 among males (28%) as among females (10%). Cisgender women represented 19% of new HIV diagnoses in 2019, so addressing this imbalance is critical to achieve adequate PrEP coverage to end the HIV epidemic.
Additional CDC data on PrEP uptake are available here.
1 2020 PrEP prescription data are preliminary and should be interpreted with caution. CDC continues to analyze the impact of the COVID-19 pandemic on filling PrEP prescriptions in state/local jurisdictions.
2 Data on race/ethnicity were not available for all PrEP prescription data and were extrapolated.
While tremendous progress has been made in reducing HIV transmission since the height of the epidemic, it’s clear that systemic factors are contributing to persistent HIV disparities and stand in the way of national goals.
To end the HIV epidemic, we need to ensure equitable access to HIV care and prevention, including PrEP. This requires that root causes and social determinants that contribute to HIV disparities be addressed, such as poverty, housing instability, unequal access to health care, lack of education, stigma, and systemic racism. CDC has recently declared racism a serious public health threat and is working to address racism as a fundamental driver of racial and ethnic health inequities in the U.S., including the inequities seen in HIV prevention and care.
Since the first studies documenting the effectiveness of PrEP, CDC has worked with numerous partners to make sure that people know about, have access to, and use PrEP effectively. Remaining barriers must be fully addressed, however, for access and use to increase equitably among all who could benefit.
CDC’s efforts have accelerated even further since 2019, when the U.S. Department of Health and Human Services (HHS) announced the federal EHE initiative. Separately, in 2019, the U.S. Preventive Services Task Force (USPSTF) issued a Grade A recommendation that clinicians should offer PrEP to people at high risk of getting HIV. The recommendation led to the requirement that PrEP be provided with no copay for nearly all people with commercial insurance and many people with public insurance. The U.S. Department of Health and Human Services also launched the Ready, Set, PrEPexternal icon program in 2019, which makes PrEP medication available at no cost to people without insurance drug coverage, regardless of income.
CDC’s key efforts include:
- CDC requires state and local health departments that receive any of the agency’s approximately $400 million annual HIV prevention and surveillance funding to incorporate PrEP into their local strategies. Activities focus on education, training, communication, and linking people who would benefit to providers.
- Through EHE, CDC awarded $109 million in 2020 and $117 million in 2021 to strengthen key HIV prevention strategies, including PrEP uptake, in 57 priority areas. CDC also provided the EHE jurisdictions some flexibility to pay for laboratory costs for screening or monitoring PrEP per CDC Guidelines for uninsured and underinsured people with EHE funds. CDC funds may also be used for mobile units and other novel engagement strategies to increase PrEP uptake.
- CDC funds community-based organizations (CBOs), which are positioned to complement the HIV prevention work of health departments, in two ways: directly, as well as indirectly through health departments. CDC’s direct funding for CBOs is providing up to $210 million over five years, through 2026, to nearly 100 CBOs in part to boost PrEP referrals. These resources are focused on Black and Hispanic/Latino people, gay and bisexual men, transgender women, Black cisgender women, and people who inject drugs. CDC will also provide an estimated $55 million to approximately 30 additional CBOs in 2022, in part to link more young Black and Hispanic/Latino gay and bisexual men; young Black and Hispanic/Latino transgender women; and their partners to PrEP services.
- CDC collaborated with the Centers for Medicare and Medicaid Services (CMS) on guidancepdf iconexternal icon from the Departments of Labor, Health and Human Services, and Treasury to clarify that nearly all commercial health plans and many public insurance plans must cover patient costs related to PrEP medication, as well as associated clinic visits and laboratory tests with no out of pocket cost to patients.
CDC also evaluates emerging science, updates clinical guidelines as new PrEP options are approved by the FDA, and develops tools and communication campaigns to help providers prescribe a growing array of PrEP options to people who could benefit. CDC will continue to work with partners to expand efforts to ensure that anyone who would benefit from PrEP can get it, and to increase use of this highly effective prevention strategy.