Despite a revolutionary prevention tool that reduces HIV risk by 99%, vulnerable populations continue to be left behind
Imagine a medical breakthrough that could reduce the risk of HIV infection by up to 99%—a tool so powerful it could potentially end one of the most devastating pandemics in human history. This isn't science fiction; it's the reality of HIV Pre-Exposure Prophylaxis (PrEP), a prevention method that has been available for over a decade. Yet, despite this revolutionary advancement, something puzzling has occurred: the promise of PrEP has not fully translated into practice, particularly for vulnerable populations.
When taken as prescribed, PrEP reduces the risk of getting HIV from sex by about 99%, making it one of the most effective preventive measures in all of clinical medicine 5 .
At urban academic medical centers—including those serving young people—countless opportunities to prescribe PrEP are being missed, allowing preventable HIV infections to occur. The story of PrEP's first decade is not just one of scientific triumph but also of persistent disparities and systemic failures that have prevented this powerful tool from reaching everyone who could benefit. This article explores the groundbreaking research exposing these gaps and the innovative solutions that could finally help realize PrEP's world-changing potential.
HIV Pre-Exposure Prophylaxis (PrEP) involves using antiretroviral medication to prevent HIV acquisition in people who are HIV-negative but at risk of infection. Think of it as a protective shield against the virus—when taken consistently, it builds a biological defense that stops HIV from establishing itself in the body.
The Centers for Disease Control and Prevention (CDC) recommends that all sexually active adults and adolescents be informed about PrEP as part of comprehensive HIV prevention, which should also include counseling on condom use, STI screening, and other risk-reduction methods 5 .
PrEP medications work by blocking the pathway that HIV uses to infect the body. When present at sufficient levels, these drugs prevent the virus from establishing a permanent infection.
Effective against sexual transmission
Effective against injection drug use transmission
Over the years, the PrEP "toolkit" has expanded significantly, offering different options to suit diverse needs and preferences:
| PrEP Type | Formulation | Effectiveness | Approved For |
|---|---|---|---|
| F/TDF (Truvada®) | Daily oral pill | ~99% when taken as prescribed | All people with sex or injection drug use risk factors |
| F/TAF (Descovy®) | Daily oral pill | ~99% when taken as prescribed | Sexual transmission (excluding receptive vaginal sex) |
| Cabotegravir (Apretude®) | Injection every 2 months | ~99% when taken as prescribed | Sexual transmission for all people |
| Lenacapavir | Injection every 6 months | Shown highly effective in trials | Currently under regulatory review 2 |
A landmark study published in 2025 examined electronic medical record data from two major academic medical centers in Chicago from 2015-2021, analyzing 53,031 medical encounters involving 9,664 individuals who had at least one negative HIV test and documented indications for PrEP 3 .
Researchers identified PrEP candidates using CDC criteria: anyone with a recent sexually transmitted infection (within six months) or documentation of injection drug use. They then tracked whether these eligible individuals actually received PrEP prescriptions during their healthcare visits, creating a comprehensive picture of real-world PrEP implementation 3 .
The findings revealed troubling disparities in PrEP prescribing patterns. The analysis used statistical models to calculate the odds of receiving a PrEP prescription across different demographic groups:
| Demographic Factor | Adjusted Odds Ratio of Receiving PrEP |
|---|---|
| Non-Hispanic White individuals | Reference (4.85 times more likely than other groups) |
| Non-Hispanic Black individuals | 0.21 (79% less likely) |
| Hispanic/Latino individuals | 0.53 (47% less likely) |
| Men who have sex with men (MSM) | Reference (24.87 times more likely) |
| Heterosexual women | 0.10 (90% less likely) |
| People who inject drugs | 0.01 (99% less likely) |
The data demonstrates that being a heterosexual woman made a person 90% less likely to receive PrEP, while injection drug users were 99% less likely to be prescribed this preventive medication, despite their clear eligibility under CDC guidelines 3 .
The study also revealed significant variations in PrEP prescribing based on where patients received care:
| Healthcare Setting | Likelihood of PrEP Prescription |
|---|---|
| Infectious Disease clinics | Highest prescribing rates |
| Primary Care settings | Moderate prescribing rates |
| Emergency Departments | 86% less likely than other settings |
| OB/GYN & Women's Health | 86% less likely than other settings |
These findings are particularly concerning because emergency departments and OB/GYN clinics often serve as crucial healthcare touchpoints for vulnerable populations who might not regularly access primary care or infectious disease specialists 3 .
Healthcare structure, costs, and provider training limitations
Judgment, discrimination, and social barriers
Lack of awareness among patients and providers
Embedding PrEP services into primary care, emergency departments, OB/GYN clinics, and mental health facilities can dramatically increase access 3 .
Remote PrEP services eliminate transportation barriers and increase privacy, particularly valuable for rural populations and young people 4 .
New options like twice-yearly lenacapavir injections could revolutionize PrEP by reducing the burden of daily pill-taking and addressing adherence challenges 2 .
Clinical trials presented at the 2025 European AIDS Conference showed this six-month injection maintains high efficacy with convenient dosing 2 .
Researchers are exploring the integration of PrEP with other health services, such as contraception and STI screening, creating "one-stop" shops for sexual health 8 .
New studies focus specifically on how to best deliver PrEP in diverse settings, moving beyond efficacy to real-world effectiveness 4 .
| Research Tool | Function in PrEP Research |
|---|---|
| Electronic Medical Record (EMR) Data | Provides real-world data on patient demographics, clinical encounters, and prescription patterns across healthcare systems 3 . |
| Mixed Effects Logistic Regression | Statistical method that accounts for multiple encounters by the same patient and changes in behavior over time 3 . |
| Consolidated Framework for Implementation Research (CFIR) | Theoretical framework that helps categorize and analyze barriers and facilitators in healthcare implementation 8 . |
| Structural Equation Modeling (SEM) | Advanced statistical technique that validates predictive models of PrEP uptake by testing multiple relationships simultaneously . |
| Qualitative Interview Guides | Semi-structured protocols that allow researchers to explore nuanced perspectives on PrEP barriers from patients and providers 8 . |
The first decade of PrEP use has revealed both extraordinary promise and sobering implementation challenges. While the development of highly effective HIV prevention methods represents a monumental scientific achievement, the persistent disparities in who actually receives PrEP remind us that medical breakthroughs alone aren't enough.
Closing the PrEP gap requires addressing structural barriers in healthcare systems, combating stigma and bias, and implementing creative delivery models that meet people where they are.
The research is clear: as we enter PrEP's second decade, the focus must shift from simply proving efficacy to ensuring equitable access.
but only if we transform our healthcare systems to ensure that revolutionary prevention tools reach everyone who needs them—regardless of their race, gender, substance use, or where they seek care.
The science has given us the tools; now we must do the work of delivering them.