PrEP in the USA: white people given preference 

An analysis by the Centers for Diseases Control and Prevention (CDC) of PrEP prescriptions between 2014 and 2016 suggests PrEP is being disproportionately provided to white people, despite African American or black (black) people being the ethnic group most affected by HIV across all key populations.

In 2015, approximately 1.1 million adults in the USA were estimated to be engaging in high-risk sexual or drug use behaviours that made them eligible for PrEP under American guidelines. Around 44% of these people were black, 26% were white, and 25% were Hispanic.

Analysing data representing around 92% of all PrEP prescriptions dispensed from US pharmacies and 60% to 86% of prescriptions dispensed from mail-order outlets, CDC found 7% of people eligible for PrEP received it in 2016. Despite black people having the greatest need for PrEP, 69% of prescriptions where race and/or ethnicity data was recorded went to white people, 13% to Hispanic people and 11% to black people.

Of the 78,360 people prescribed PrEP in 2016, 5% were women – equivalent to 2% of the heterosexual women estimated to be eligible for PrEP in the USA. Among female PrEP users where race/ethnicity data was available (1,146 women), 48% were white, 26% were black, and 17% were Hispanic.

When analysed for location, 27% of people being prescribed PrEP lived in America’s southern states, despite the South being home to around half of all people diagnosed with HIV in the country in 2016. 

The CDC analysis indicates around two-thirds of PrEP users are aged between 25 and 44, suggesting younger people from key populations are not accessing PrEP. Young people (aged 13-24) accounted for one in five (22%) new HIV infections in 2015, according to CDC.

Most people (81%) being prescribed PrEP are paying for it through commercial health insurance schemes, while 12% are being funded through Medicaid. The number of PrEP users receiving medication assistance from drug manufacturers increased significantly between 2014 to 2016, from 435 to 5,437.

Race or ethnicity information was not available for 58% of the data analysed by CDC. Records were also excluded from the analysis if people had any history of HIV or hepatitis B diagnosis preceding their initial PrEP prescription. However, in 31% of cases, the data analysed did not include this information. This might have resulted in an overestimate of PrEP users due to the inclusion of people potentially using antiretrovirals for treatment rather than prevention purposes. In addition, people with prescriptions for 30 days or more were defined as post-exposure prophylaxis users and excluded. 

Although race/ethnicity data were not available for many PrEP users, the low proportion of women and black and Hispanic people being offered PrEP, and the overall gap between those in need of PrEP and those being prescribed it, suggests significant barriers to PrEP access exist. These barriers need to be better understood and addressed for PrEP to become truly effective as a tool for preventing HIV.