PrEP underprescribed in young women despite need

Preexposure prophylaxis (PrEP) is prescribed less to young women at an increased risk for HIV than to young men, according to the results of a study called ‘Differences in Sexual Health Clinic Services by Age and Gender in Metropolitan Boston’ published recently in Sexually Transmitted Diseases.

A team of researchers led by Anne Neilan, M.D., MPH, of the Medical Practice Evaluation Center and Department of Medicine at Mass General Brigham, analyzed the data from 7,949 visits by 4,004 individuals at a Boston metropolitan area sexual health clinic.

Neilan and her team stratified the data into four age groups, including 15–22, 22–26, 26–45 and 45 and older.

Someone is considered a good candidate for PrEP if they have had anal or vaginal sex within the last six months, have had an STI diagnosis within the last six months, have more than one sexual partner of an unknown HIV status, have a sexual partner who is HIV positive or have shared drug injection equipment within the last six months.

“Visits with young patients had the highest proportion of uninsured and those with no prior knowledge of PrEP,” Neilan and her team said. “These findings are striking in Massachusetts, a state with high rates of health insurance.”

They discovered that cisgender females at or under the age of 26 were 63% less likely to be prescribed PrEP during their visit than their male counterparts. Only 17% of cisgender females under the age of 22, who were candidates for PrEP, received a prescription.

A PrEP indication was identified in 38% of visits and yet prescribed at 84% and only 61% of male and female visits, respectively. Women 26 years or younger were 46% less likely to be prescribed PrEP than women older than 26.

“Concerningly, we also found that visits attended by Black individuals were 17% less likely than those attended by White individuals to have PrEP prescribed, mirroring national trends,” Neilan and her team continued.

Most (81%) new HIV infections in the United States occur among people assigned male at birth, partly because PrEP advertising has historically focused on cisgender males and transgender women. However, in 2022, 50% of the 6,980 HIV diagnoses made in females ages 13 and older were in Black women.

Despite adolescents and young adults making up only one-quarter of the sexually active population in the United States, they account for approximately half of all new sexually transmitted infections.

Reasons adolescents may forego treatment include fears that their sexual activity will be disclosed through the parents’ insurance and decreased access to preventative care services.

“Addressing disparities by age, gender and race/ethnicity in PrEP prescriptions is critical,” Neilan and her team write in the study. “Gaps between PrEP need and prescription may also reflect patient preferences or other barriers such as the need for quarterly visits for oral PrEP, anticipated costs or provider-related barriers (e.g., provider not offering PrEP due to limited knowledge, failure to consider PrEP for non-men who have sex with men, perceptions of patient adherence ability, implicit bias or uncertainty about legality for minors).”