Trends in PrEP inequity by race and census region, United States, 2012-2021

BACKGROUND: PrEP was approved for HIV prevention in the US in 2012; uptake has been slow. Black and Hispanic people have higher rates of new HIV diagnoses than White non-Hispanic people in the US. We describe the inequitable use of PrEP by race within US regions from 2012-2021.
METHODS: We used commercial pharmacy data to enumerate PrEP users by race and US Census region from 2012-2021. Race/ethnicity data were available for 124,835 (34%) of PrEP users; to estimate total PrEP users by race, we assumed that the racial distribution was the same in PrEP users with missing race data as in those with reported race data. The PrEP-to-Need Ratio (PnR), a metric of PrEP equity, was defined as the number of PrEP users in a group divided by the number of new diagnoses in that group in the same year.
RESULTS: PnR increased from 2012-2021 for all races and regions, but levels of PrEP use were not consistent across regions (See Figure) and were not equitable (defined by differences in PnR by race/ethnicity). In all regions, PnR was highest for White and lowest for Black people. By region, the highest region- and race-specific PnR was for White people in the Northeast in 2021: the PnR was 48.7 and the absolute difference in White versus Black PnRs was 44.5 (White:48.7; Black:4.2).
CONCLUSIONS: Prevention programs should be guided by PrEP equity (use relative to epidemic impact), not PrEP equality (equal use in groups, regardless of HIV diagnosis proportion). By this measure, US prevention programs in all regions demonstrated decreasing PrEP equity over time (e.g., larger gaps in PnR by race/ethnicity). The US South lagged all regions in equitable PrEP use, with the lowest PnR overall compared to other US regions. Better programs are needed to provide PrEP to people at greatest risk for HIV infection.