The Gaps in PrEP Use Are Real. We Can Improve Uptake.

— Informing patients of their options and reducing barriers to access are key

No patient today should face the risk of acquiring HIV. That means we need to focus our attention on people who could benefit from HIV preexposure prophylaxis (PrEP) but are not receiving it. Reaching them requires us to look at to whom we offer PrEP, which form of PrEP is offered, and whether the patient can actually obtain it.

An April studyopens in a new tab or window in JAMA Pediatrics makes the missed opportunity especially hard to dismiss. Researchers examined claims from 2018 through 2022 for 100,536 commercially insured people ages 13 to 21 with a documented bacterial sexually transmitted infection (STI) or high-risk sexual behavior -- indicators of potential benefit from PrEP. Despite their insured status and having reached a clinician, only 1.6% filled a PrEP prescription during follow-up.

Minority and female population experiences illustrate the cost of low PrEP uptake. According to AIDSVu's latest estimatesopens in a new tab or window, Black people accounted for 15% of PrEP users in 2025 but 39% of new HIV diagnoses in 2024. Hispanic people accounted for 18% of users and 34% of diagnoses in those years. Women accounted for 10% of users and 20% of diagnoses.

Those findings call for new approaches to ordinary clinical encounters.

CDC guidance already advises cliniciansopens in a new tab or window to inform all sexually active adults and adolescents about PrEP and to prescribe it to those who request it where clinically appropriate, even when they do not disclose risk factors. Women specifically should routinely hear about HIV prevention during primary care and reproductive health visits. Likewise, pediatric visits must encompass a patient-appropriate discussion about HIV prevention, including offering PrEP.

Waiting for a patient to volunteer a detailed sexual history puts a great deal of faith in a conversation that may not yet feel safe. For an adolescent, the first concern may be whether a parent will find out. We should not assume adults are immune to privacy concerns, and these concerns deserve a concrete discussion, including the limits of confidentiality under applicable law.

For others, daily dosing carries an unwelcome reminder of stigma or is difficult to maintain. An appointment every few months may be manageable when a daily pill is not. Infectious diseases physician and HIV/AIDS prevention specialist Kenneth Mayer, MD, reportsopens in a new tab or window that Fenway Health has seen a substantial increase in overall PrEP prescriptions as additional options have become available. His observation speaks directly to the patients missing from today's filled prescription totals.

Medical history and route of exposure help determine which PrEP formulations are suitable. But patient preferences also belong in the conversation. The choices are increasing. A daily oral has been available since 2012. Today, injections can be given every 2 months after initiation or every 6 monthsopens in a new tab or window, depending on the product. Clinical trials show the promise of a monthly oral PrEPopens in a new tab or window.

While a young woman who cannot keep a pill bottle private may welcome an injection, another patient may struggle with fear of needles. Adherence to a monthly oral option may be easier for some patients than a daily pill. Longer-acting options make it easier for patients who struggle to get time off for appointments.

For patients who previously declined or stopped PrEP or struggled with adherence or side effects, clinicians should seize an opportunity to revisit the available choices. A conversation that ended with difficulty taking a daily pill deserves another attempt when different regimens are available. The same is true when employment, housing, or relationships change. A prior decision should not become a permanent assumption.

Writing a PrEP prescription is not where care is supposed to end. Practices should determine whether patients actually start on the medication. If a prescription is not filled, we should find out why. If an injection is preferred but unavailable in a practice, the response should be to help arrange access and follow-up.

As a lawyer working on preventive services coverage, I find it especially frustrating when a patient's ability to maintain PrEP is blocked by an insurance restriction. The Affordable Care Act's protection against cost sharing for recommended prevention is supposed to make it easier to start PrEP, which has been recommended by the U.S. Preventive Services Task Force since 2019.

Federal guidanceopens in a new tab or window already prohibits insurance plans subject to the coverage requirement from steering patients to certain PrEP products. Some insurers take advantage of the guidance's reference to the three PrEP formulations available at the time it was issued. That is not how the law should be read.

Agencies should expressly confirm coverage of all FDA-approved PrEP formulations, as CMS did for PrEP coverage under Medicare Part Bopens in a new tab or window. This unambiguous approach ensures that coverage is dynamic and access to future PrEP products is not delayed.

Coverage checks must include required testing and administration so an unexpected bill does not end prevention after the patient has finally agreed to begin. These steps matter most for people who have already had difficulty finding care they can use.

We cannot expect to end HIV transmission if we leave patients unaware that prevention is an option or fail to offer them a meaningful choice of PrEP options. Let's commit to closing every gap and removing every barrier.