Only 2% of at-risk adolescents are using PrEP, study finds

Approximately 2% of adolescents at risk for HIV filled a preexposure prophylaxis (PrEP) prescription from 2018 to 2022 in the United States, according to a recent study published in JAMA Pediatrics.

PrEP is the highly effective medication that reduces a person’s likelihood of getting HIV by approximately 99%. The PrEP methods measured in this study were emtricitabine and tenofovir disoproxil fumarate, emtricitabine and tenofovir alafenamide or injectable cabotegravir.

The study was led by Nicholas Venturelli, M.D., M.P.H., from the department of infectious diseases at Boston Children's Hospital.

Venturelli and his team used the national Merative MarketScan Research Database of employer-based insurance claims to gather the data of 100,536 participants, ages 13 to 21, with a documented sexually transmitted infection (STI) or high-risk sexual behavior, defined as condomless sex and having multiple sexual partners.

Of the participants, 71% were female, 56% had an ICD-10 code for high-risk sexual behavior, 49% had a code for an STI and 5% had both.

The researchers found that PrEP usage was impacted by age, gender and geographic location.

Specifically, patients ages 20 to 21 were three times more likely than minors ages 13 to 17 years to receive PrEP. This suggests that younger adolescents face unique hurdles, likely involving parental consent laws, lack of transportation or a hesitation to discuss sexual health with pediatricians.

Gender disparities were even more pronounced. The study found that young men were 15 times more likely than young women to fill a PrEP prescription. This may stem from a prevailing public health narrative that has historically framed HIV as a primary concern for men who have sex with men, inadvertently leaving young women out, even though women made up nearly three quarters of the study’s population.

Where a young person lives in the United States also dictates their likelihood of receiving care. The study noted that while more than half of the at-risk participants (52%) lived in the South, this region suffered from significantly lower fill rates compared to the Northeast.

Relative to fill rates in the Northeast, they were 26% lower in the Midwest and 31% lower in the South. These inequalities could be attributed to a lack of awareness about PrEP, stigma and structural and social barriers to healthcare.

The researchers suggest that these geographic inequalities are a direct result of structural and social barriers, which include a lack of specialized clinics, inadequate insurance coverage, and the persistent "Stigma of the South" regarding sexual health education.

In the United States, youths ages 13 to 24 account for approximately 20% of all new HIV infections, a statistic that underscores the importance of preventing HIV in this population, the researchers said in the study. They add that interventions are especially effective when coming from a pediatrician.

"Confidential conversations with adolescents are essential, yet more than half of youths report not having had time alone with a health care professional,” Venturelli and his team write in the study. “Additionally, pediatricians require more training in sexual health screening and PrEP counseling; more than 50% report never discussing PrEP with their patients.”