Q: How would you summarize your study for a lay audience?

Although adolescents and young adults comprise only one quarter of the sexually active population in the United States, approximately half of new sexually transmitted infections (STIs) are diagnosed in people of these ages. Compared to older adults, little is known about how teens and young adults access and use services like STI screening and treatment, sexual health vaccinations and HIV pre-exposure prophylaxis (PrEP). PrEP is a preventive medicine for people who do not have HIV but are at increased risk of exposure.

Our study examined how people of different ages and genders used sexual health services in a Boston-based clinic that provides free, comprehensive services across six hospital- and community-based sites. While our study focused on a single metropolitan area, our findings reflect broader national challenges in sexual health service utilization.

Q: What question were you investigating?

We set out to learn whether adolescents and young adults who interacted with the Massachusetts General Hospital Sexual Health Clinic utilized sexual health services differently than older adults. We also aimed to identify opportunities to increase patient engagement and deliver existing services more consistently and equitably to those who need them most.

Q: What methods or approach did you use?

We analyzed data from 7,949 visits to the Sexual Health Clinic, made by 4,004 individuals, between January 2019 to June 2021. We grouped data on visits, STI diagnoses, PrEP use and health insurance by age and gender. We then used statistical analysis to examine how outcomes—such as being prescribed preventive PrEP—were associated with factors like age and gender.

Q: What did you find?

We found that among patients at increased risk for HIV exposure, PrEP prescribing differed by age and gender. For example, cisgender males who were 26 years old or under with PrEP indications were prescribed the medicine at slightly higher rates (86%) than their counterparts over age 26 (83%). However, among cisgender females at increased risk, only 20% of those at or under age 26 were prescribed PrEP compared to 72% of those over age 26.

Looking at the data from another angle, we discovered that young cisgender females (at or under age 26) were 63% less likely to be prescribed PrEP during their visits than young cisgender males. Additionally, only 17% of visits attended by even younger cisgender females (under age 22) who were candidates for PrEP received it.

Q: What are the implications?

Addressing disparities by age, gender and race/ethnicity in HIV prevention—via PrEP prescriptions—is critical. Significant gaps for young cisgender females with PrEP indications reflect opportunities for improved programming tailored to this population, with the potential to avert new HIV diagnoses.

Gaps between PrEP need and prescription may also reflect patient preferences or other barriers such as the need for quarterly visits for oral PrEP or anticipated costs. They could also reflect provider-related barriers, such as limited knowledge of the drug or failure to consider PrEP for individuals other than men who have sex with men. Policy efforts focused on alleviating these barriers may help reduce HIV incidence by improving how well PrEP reaches those who would benefit from it.

Q: What are the next steps?

Future work should explore why PrEP prescription rates among young cisgender females are much lower than their counterparts, as well as evaluate targeted interventions to improve PrEP access for indicated young women.

Authorship: In addition to Neilan and Ard, Mass General Brigham authors include Yiqi Qian, Grace Chamberlin, Scott E. Hadland, Madhava Narasimhadevara, Vandana Madhavan and Fatma M. Shebl.

Paper cited: Neilan, A., et al. “Differences in Sexual Health Clinic Services by Age and Gender in Metropolitan Boston.” Sexually Transmitted Diseases. DOI: 10.1097/OLQ.0000000000002275

Funding: This work was supported by the Morton N. Swartz Transformative Scholar Award in Infectious Diseases, the Claflin Distinguished Scholars Award and the Eunice Kennedy Shriver National Institute for Child Health and Human Development (K08 HD094638-S).

Disclosures: None.

The guideline is published on World AIDS Day, December 1, 2025, to raise awareness of new approaches to prevention.

Pre-exposure prophylaxis involves an HIV-negative person starting antiretroviral medications before potential HIV exposures occur in order to prevent infection. Postexposure prophylaxis involves taking 28 days of antiretrovirals right after a potential exposure to HIV.

“Canada is not at all on track to achieve its goal of eliminating HIV as a public health threat by 2030. Our aim with this guideline is to support front-line health care providers, policy-makers, community members, and others in expanding the use of these safe and effective tools for preventing HIV,” says Dr. Darrell Tan, lead author and infectious disease physician at St. Michael’s Hospital, Toronto, Ontario. “A wide array of PrEP and PEP options now exists in Canada. We need to urgently expand their use until all people have equitable access to prevention strategies that they find suitable.”

HIV infections in Canada are concentrated in specific populations, with 38% of new infections in gay, bisexual, and other men having sex with men (GBM); 25% in people who inject drugs (PWID); and 4% in GBM-PWID. More than one-third of infections occur in females. Some Indigenous communities are particularly heavily affected, with more cases in Saskatchewan and Manitoba than the national average.

The guideline, an update to 2017 guidance, was developed through the Canadian Institutes of Health Research (CIHR) Pan-Canadian Network for HIV and STBBI (sexually transmitted and blood-borne infections) Clinical Trials Research (CTN+). It includes easy reference tables with recommendations on medication regimens, indications, monitoring, and more.

Key differences from the 2017 guideline include the “explicit inclusion of self-identified need as a reason for PrEP initiation” and the expanding range of available PrEP choices, with newer regimens including an injection given every 2 months.

The authors’ aim is to support clinical decision-making in primary care, infectious diseases, emergency medicine, sexual health, nursing, pharmacy, and related disciplines, as well as community workers who promote PrEP and PEP.

“Because lack of PrEP and PEP awareness among key populations and clinicians is a common barrier to implementation, public health officials, professional societies, and other trusted authorities should play leadership roles in promoting these strategies in collaboration with community organizations and tracking uptake in conjunction with HIV surveillance data,” the authors write. “Information should be framed in a positive light to counteract the stigma and apprehension that sometimes surround PrEP and PEP.”

But even with this positive news about increasing use of pre-exposure prophylaxis or PrEP, the study also suggests that health care providers and public health agencies could do more to promote consistent use of these medications.

The new study, done by a team at the University of Michigan Medical School, uses national pharmacy data to look at prescriptions for oral PrEP from 2016 to 2023 among people ages 18 to 25. It’s published in the Journal of General Internal Medicine.

At the start of the study period, 26 of every 100,000 U.S. young adults filled a prescription for PrEP, but this rose to more than 208 by the end of 2023. Prescription dispensing was lower for those ages 18 to 21 than for those ages 22 to 25.

However, the length of time that a person kept refilling their prescription dropped by more than two weeks during this time. This may suggest inconsistent use of PrEP, or trouble keeping up with the regular appointments and tests needed to continue the medication.

It’s the first large study to focus just on this age group, which has an especially high risk of HIV transmission. PrEP, when taken consistently and as prescribed, can reduce the chances of acquiring HIV through sex by 99%.

It’s also an age group that doesn’t see the doctor often, notes Nina Hill, M.D., the lead author of the study.

Hill is a general internist and pediatrician at U-M, a National Clinician Scholar at the U-M Institute for Healthcare Policy and Innovation, and a postdoctoral fellow in the Susan B. Meister Child Health Evaluation and Research Center.

“This is a patient population we often neglect in health care, because we we don’t think about them belonging to pediatric care or adult care, and their stage of cognitive development means they underestimate their STI risk in general — yet they’re one of the highest risk groups for a new diagnosis of HIV,” she said. “We’re encouraged to see more prescribing over time, but the question remains: are we getting it to the highest-risk patients?”

She notes the number of steps needed to get to consistent PrEP use: getting screened by a provider or online screening tool to determine if PrEP is appropriate, seeing a provider for the initial exam and tests for HIV and other sexually transmitted infections (STIs), receiving and filling a prescription, and keeping up with regular tests of kidney function, HIV and other STIs every three to six months.

Even patients who decide to take their PrEP pills on an episodic rather than daily basis – before time periods when they will be sexually active with new partners, for instance – need to have consistent access.

Either way, she says, it’s important for young adults, their health care providers, and the adults they trust most to discuss their sexual health, and to be aware of the availability of PrEP and its power to prevent HIV.

More about the findings

In all, Hill and her colleagues looked at 1.45 million prescriptions dispensed to nearly 240,000 young adults with an average age of 22. Most (87%) were male, but Hill notes that certain women are also at risk for HIV and might be eligible for PrEP.

Just over a third of the young adults taking PrEP lived in the southern U.S., an area where HIV transmission is especially high. And the rate of PrEP dispensing started lowest but rose fastest in this region during the study period.

The study covers a period when the first PrEP medication, introduced in 2012 under the brand name Truvada, also became available as a generic drug in 2020, and a second oral PrEP option called Descovy went on the market in 2019. Though an injectable form of PrEP received approval in 2021, few young adults received this treatment so they were excluded from the study.

More than 70% of the prescriptions during the study period were for Truvada or its generic equivalent.

Hill and her colleagues also looked at what kind of health care provider prescribed PrEP to each person who filled a prescription.

Nurse practitioners accounted for 39% of prescriptions, with family medicine or general practitioners accounting for 22%, and internal medicine physicians and physician assistants accounting for 14% and 11%, respectively.

Although emergency medicine physicians accounted for a very small percentage overall, the number of prescriptions written by them increased tenfold during the study period.

PrEP has been recommended since 2019 by the U.S. Preventive Services Task Force for adolescents and adults who have an increased risk of acquiring HIV.  All individuals should be screened for HIV at least once in their lifetime between ages 15 and 65 years. Under the Affordable Care Act, most insurance programs must make PrEP and HIV screening available to patients at no cost if they meet USPSTF criteria.

However, the status of that coverage is the subject of a case called Braidwood v. Kennedy that was recently heard before the U.S. Supreme Court; a ruling is expected soon.

More information about PrEP is available via the HIV.gov site: https://www.hiv.gov/hiv-basics/hiv-prevention/using-hiv-medication-to-reduce-risk/pre-exposure-prophylaxis .

Hill and senior author Kao-Ping Chua, M.D., Ph.D., and their co-author Sijia He, M.S., are part of the Susan B. Meister Child Health Evaluation and Research Center, which Chua directs. Hill is supported by the National Clinician Scholars Program, the Susan B. Meister Child Health Evaluation and Research Center, and a training grant (T32HS000053) from the Agency for Healthcare Research and Quality.

National Trends in HIV Pre-Exposure Prophylaxis Dispensing to Young Adults, 2016–2023, Journal of General Internal Medicine, DOI:10.1007/s11606-025-09574-8

Data were obtained from the IQVIA Real-World Longitudinal Prescription Data database (IQVIA), which included more than 95% of US retail pharmacy and more than 75% of mail order pharmacy prescriptions.³ Prescription claims, medical claims, and demographics databases were linked,³ allowing us to measure prescriptions for a single patient over multiple years and describe demographic and payer information by medication type.

To identify persons prescribed PrEP, we used a validated algorithm.^3,4 We estimated the cumulative and monthly number of persons aged 13 years or older prescribed PrEP by medication type from January 2013 to December 2023. Cumulative estimates were deduplicated by patient ID. Monthly estimates were deduplicated only by medication type because a person might be prescribed more than 1 type of PrEP in a given month. We used χ² tests to assess whether demographic characteristics (Table) of PrEP users were significantly different by medication type in 2023. Analyses were conducted using SAS version 9.4 (SAS Institute). Alpha of .05 (2-sided) defined statistical significance. This study was determined by the Centers for Disease Control and Prevention to be exempt from institutional review board review. This study was reported using STROBE reporting guidelines.

From January 2013 to December 2023, a cumulative 1 126 878 persons were prescribed oral or injectable PrEP, 88.6% of whom were male. The annual number of PrEP users increased from 10 281 in 2013 to 505 730 in 2023.

The monthly use of branded TDF/FTC increased from January 2013 to September 2019, but decreased after branded TAF/FTC and generic TDF/FTC became available (Figure). From December 2021 to December 2023, generic TDF/FTC had the highest monthly share of users among all medications (74 319 vs 74 106 for TAF/FTC; 11 002 for branded TDF/FTC).

A cumulative 99% of persons prescribed PrEP from 2013 to 2023 were prescribed oral PrEP. Since injectable cabotegravir became available in early 2022, it has been prescribed for a cumulative 15 428 persons. From 2022 to 2023, the percentage of PrEP users prescribed cabotegravir increased from 1.1% to 2.5%.

In 2023, generic TDF/FTC was the predominant form of PrEP prescribed (53.4%) (Table). Significant differences in age and region by medication were found, although differences by sex and insurance were even more pronounced. Of persons prescribed branded TDF/FTC, 29.3% were female compared with 2.5% for branded TAF/FTC (P < .001). More users of generic TDF/FTC had private insurance (70.9%) vs those prescribed branded TAF/FTC (54.6%) and TDF/FTC (28.6%) (P < .001); 22.3% of those prescribed generic PrEP had public insurance, similar to the percentages using branded medications.

PrEP use increased between 2013 and 2023, with generic TDF/FTC being the most frequently prescribed medication since 2021. Injectable PrEP use was low likely because of barriers such as the high cost of stocking this expensive medication in clinics. The lower proportion of persons prescribed generic TDF/FTC with public insurance vs private insurance may be attributed to use of 340B programs with prescribing of branded medications required for manufacturer rebates.

New PrEP medications are heavily marketed, yet, generic PrEP dominated the market despite the availability of 3 branded medications. This could be attributed to a 2021 federal guidance directing insurers to cover the cost of generic PrEP medication without patient cost-sharing,⁵ suggesting that effective health policy can result in lower health care expenditures.

Study limitations include that IQVIA did not capture prescriptions in organizations, such as Kaiser Permanente and the Veterans Administration, and did not include information about the current gender of PrEP users, so transgender users could not be identified. Also, PrEP use by race and ethnicity was not assessed because this information was missing for most users, and payer information was missing for about 20%.

Studying PrEP prescribing patterns is necessary to monitor progress in the efforts to increase PrEP use and end HIV spread.

Accepted for Publication: September 26, 2024.

Published Online: October 14, 2024. doi:10.1001/jama.2024.21493

Corresponding Author: Laura M. Mann, PhD, MPH, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, Atlanta, GA 30329 (lmann@cdc.gov).

Author Contributions: Drs Mann and Zhu had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Mann, Zhu, Huang, Neblett Fanfair, Hoover.

Acquisition, analysis, or interpretation of data: Mann, Zhu, Huang, Kourtis, Hoover.

Drafting of the manuscript: Mann, Zhu, Hoover.

Critical review of the manuscript for important intellectual content: Zhu, Huang, Kourtis, Neblett Fanfair, Hoover.

Statistical analysis: Mann, Zhu, Huang.

Administrative, technical, or material support: Mann, Huang.

Supervision: Huang, Kourtis, Neblett Fanfair, Hoover.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was funded by the Centers for Disease Control and Prevention (CDC).

Role of the Funder/Sponsor: The CDC had a role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The findings and conclusions in this study are those of the authors and do not necessarily represent the official position of the CDC.

Data Sharing Statement: See the Supplement.

The study, published today in Health Affairs, was designed, in part, to explore the impact that out-of-pocket cost increases could have, depending on the outcome of an ongoing court case challenging certain provisions of the 2010 Affordable Care Act (ACA).

The researchers used a large, proprietary database of medical and pharmacy claims to determine the rates at which patients failed to fill (i.e., abandoned) insurer-approved PrEP prescriptions at different levels of out-of-pocket costs. Their findings suggest that even a small increase, from $0 to $10 in monthly PrEP out-of-pocket costs, would double the rate of PrEP prescription abandonment. Further, an increase in out-of-pocket costs to between $100 and $500 per month would result in nearly one-third of patients abandoning their PrEP prescriptions.

The analysis also highlighted the negative consequences of abandoning PrEP: The rate of new HIV infections in the year after the initial PrEP prescription was two to three times higher among those who never filled those prescriptions.

“Our findings suggest that out-of-pocket cost increases for PrEP could upend the progress that has been made towards ending the HIV/AIDS epidemic in the United States,” said study senior author Jalpa Doshi, PhD, a professor of Medicine and the director of Value-based Insurance Design Initiatives at the Center for Health Incentives and Behavioral Economics at Penn Medicine.

To date, the FDA has approved two HIV PrEP products, each of which combines two standard antiretroviral drugs in a single pill. For the past decade, the U.S. Centers for Disease Control and Prevention (CDC) has recommended PrEP as a way of preventing HIV infection among higher-risk individuals. Expanding access to PrEP is also one of the central pillars of the CDC’s Ending the HIV Epidemic in the U.S. (EHE) initiative, which seeks to reduce new HIV infections in the United States by 90% by 2030. In 2019, the U.S. Preventive Services Task Force (USPSTF), an independent group of experts on disease prevention, gave PrEP an “A” rating. Under a provision of the ACA, that rating has meant that, since 2021, most private insurance plans have been required to provide PrEP to policyholders without cost sharing.

However, an ongoing legal challenge (Braidwood Management, Inc. v. Becerra) may nullify that part of the ACA, allowing insurers to now require out-of-pocket costs for PrEP and other preventive therapies. Against this background, Doshi and her colleagues sought to gauge how out-of-pocket cost changes affect PrEP use.

The team reviewed a U.S.-wide database covering insurer-provided health care, including prescription records, dating from 2016-2018. They analyzed this dataset to determine the rate of PrEP prescription abandonment—defined as a patient not picking up their newly-prescribed and insurer-approved PrEP prescription from the pharmacy within 365 days —at different out-of-pocket cost levels. Their analysis covered 58,529 patients with new, insurer-approved PrEP prescriptions, and adjusted for differences among the patients. Refills did not feature in the analysis.

They found that both the rate of PrEP prescription abandonment and the rate of delayed prescription fills increased as out-of-pocket costs rose. Also, patients who abandoned their PrEP prescription were two to three times more likely to get infected with HIV in the following year, compared to those who filled their PrEP prescription.

Based on their analyses, the researchers estimated that raising monthly patient out-of-pocket costs for PrEP from $0 to the $1-$10 category would nearly double the prescription abandonment rate (from 5.6 percent to 11.1 percent), while moving to the $101-$500 category the abandonment rate would be 34.7 percent. At the $500+ category, they estimated, the abandonment rate would be about 42.6 percent, nearly eight times the rate at the $0 level.

Overall, the results suggest that even a modest increase in patient out-of-pocket costs for PrEP could result in a sharp increase in prescription abandonment—and a subsequent large increase in the rate of new HIV infections.

The study was co-led by Lorraine Dean, ScD, Associate Professor at the Johns Hopkins Bloomberg School of Public Health. The research was supported by the National Institutes of Health (R21NR018387, R01NR017573, R25MH083620, and T32AI102623).

Research published in the Journal of Prevention and Health Promotion from a team at the University of Bath finds that knowledge and awareness among young men who have sex with other men about the drug is low and there is often stigma associated with being prescribed PrEP.

Pre-exposure prophylaxis ‘PrEP’ refers to a pill that prevents HIV contraction in HIV-negative individuals. PrEP can be taken daily or on-demand a day before and for two days after sex. When taken as prescribed it is 99% effective at preventing HIV transmission. Since March 2020, PrEP has also been available for free on the NHS for those at high risk of HIV.

PrEP Awareness Week and WAD23

The latest study is published during PrEP Awareness Week and on World Aids Day (Friday 1 December). It comes at a time when concerns over access to the drug, as well as HIV treatment, have been in the news.

On Thursday, results of a large-scale PrEP Impact Trial involving 24,000 PrEP users published in The Lancet suggested the drug was highly effective as a preventative treatment. On Wednesday, musician Sir Elton John spoke in Parliament urging ministers to do more to hit the target of eliminating new HIV cases by 2030.

Despite higher risks of contracting HIV, uptake of PrEP among young men who have sex with other men is low in the UK. This latest study from researchers at Bath investigated why this was the case through in-depth interviews with a small sample of young men aged between 18 – 22.

Their study highlights barriers to uptake identified by those most at risk of contracting HIV and who could benefit from the treatment. These included a lack of a perceived necessity to take PrEP, a lack of general knowledge about the drug – what it is and how it works; as well as discomfort in getting hold of the drug.

Anonymous responses from participants highlighted specific challenges. For example, some men felt that taking PrEP was unnecessary:

I always just engaged in safe sex so it’s like, do I need this added preventative measure if I’m already sort of like I’m doing what I should be doing?

Others saw STI screening as a solution, without considering the possibility of contracting HIV in between testing. Participants often lacked a full picture of why and how they might use PrEP, and suggested finding it difficult to access detailed information:

I didn’t know if I really needed it, like there wasn’t really advertisements or like actual people or like poster advertisements telling me that I probably need PrEP.

Regarding access to PrEP, participants also referred to awkward consultations with GPs or sexual health clinics where requesting PrEP had a perceived stigma attached:

Being in person with them and they say something awkward, and you just have to sort of sit there and then leave awkwardly it’s a lot more intense.

The researchers’ analysis backs up a recent government review which suggests that a large proportion of young men who could be taking PrEP are not.

Against this backdrop, the researchers think more could and should be done to increase access to the drug, including through the implementation of new online services and increased education.

Dr Richard Hamshaw from the University of Bath’s Department of Psychology supervised the research. He said: “Given the roll-out of PrEP, we were keen to gather views from one of the more at-risk groups (and most targeted group for PrEP uptake), young men who have sex with men.

“Carrying out in-depth interviews meant our participants could share their stories and experiences with us, and we were able to build a more detailed picture as to why some people might not use PrEP. We hope that our paper sheds further light on barriers to PrEP uptake, and hope to explore this further in future projects.”

First author Loukas Haggipavlou added: “I started researching PrEP uptake after I noticed a worrying number of my LGBT+ friends were relatively unaware of the drug. Following this study, we propose enhancing such awareness by promoting stories from PrEP users about its consumption and benefits, coupled with integrating PrEP discussions into sex education in schools.

“To further increase uptake amongst young men who have sex with men, we also recommend the implementation of new online services for PrEP acquisition, to simplify the process, destigmatise and increase access.”