PrEP Underprescribed: Young Women at High Risk for HIV Miss Prevention

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. A study published in Sexually Transmitted Diseases titled "Differences in Sexual Health Clinic Services by Age and Gender in Metropolitan Boston," 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 the study focused on a single metropolitan area, the findings reflect broader national challenges in sexual health service utilization. The researchers 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. The team also aimed to identify opportunities to increase patient engagement and deliver existing services more consistently and equitably to those who need them most. The researchers analyzed data from 7,949 visits to the Sexual Health Clinic, made by 4,004 individuals, between January 2019 to June 2021. They grouped data on visits, STI diagnoses, PrEP use and health insurance by age and gender. They used statistical analysis to examine how outcomes—such as being prescribed preventive PrEP—were associated with factors like age and gender. The team 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, the team 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. 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. 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. Anne Neilan, MD, MPH, of the Medical Practice Evaluation Center (MPEC) and Department of Medicine at Mass General Brigham, and Kevin Ard, MD, MPH, also of the Department of Medicine, are the lead and senior authors of the paper.