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Objectives. HIV preexposure prophylaxis (PrEP) use has increased since its US Food and Drug Administration approval in 2012. Our objective was to describe trends in PrEP use by US women. Methods. Using national pharmacy and HIV surveillance data, we calculated the PrEP-to-diagnosis ratio (PDR), a measure of PrEP prescriptions each year compared with HIV diagnoses the previous year, for women from 2017 to 2023. We also calculated PDRs in 2023 for the 20 counties with the highest numbers of diagnosed HIV infections among women and reviewed reports of public health activities conducted by recipients of Centers for Disease Control and Prevention HIV prevention funding. Results. The PDR for women was 1.5 in 2017, and it increased to 5.8 by 2023. In the 20 counties with the highest number of diagnosed HIV infections among women, PDRs ranged from 2.2 to 16.9. Counties With the highest PDRs conducted PrEP activities designed for women. Conclusions. PrEP is a highly effective HIV prevention intervention that can empower women to protect their health, but its use has been low. Public health and clinical interventions designed for women can increase their PrEP use and support ending the US HIV epidemic. (Am J Public Health. 2025;115(6):920-923.
Objectives. HIV preexposure prophylaxis (PrEP) use has increased since its US Food and Drug Administration approval in 2012. Our objective was to describe trends in PrEP use by US women.
Methods. Using national pharmacy and HIV surveillance data, we calculated the PrEP-to-diagnosis ratio (PDR), a measure of PrEP prescriptions each year compared with HIV diagnoses the previous year, for women from 2017 to 2023. We also calculated PDRs in 2023 for the 20 counties with the highest numbers of diagnosed HIV infections among women and reviewed reports of public health activities conducted by recipients of Centers for Disease Control and Prevention HIV prevention funding.
Results. The PDR for women was 1.5 in 2017, and it increased to 5.8 by 2023. In the 20 counties with the highest number of diagnosed HIV infections among women, PDRs ranged from 2.2 to 16.9. Counties With the highest PDRs conducted PrEP activities designed for women.
Conclusions. PrEP is a highly effective HIV prevention intervention that can empower women to protect their health, but its use has been low. Public health and clinical interventions designed for women can increase their PrEP use and support ending the US HIV epidemic. (Am J Public Health. 2025;115(6):920-923.
ignificant progress has been made S in reducing HIV transmission in the United States, but systemic factors and long-standing inequities have contributed to ongoing racial and ethnic disparities.' In 2022, Black women were 13% of the US female population but accounted for 50% of HIV diagnoses among women. HIV preexposure prophylaxis (РГЕР) has been recommended by the Centers for Disease Control and Prevention (CDC) since 2014.7 PrEP can reduce the risk of sexual HIV acquisition by up to 99% 3 Although PrEP use has increased among men, its use remains low among women, with only 8% of PrEP prescriptions for women in 2023 The Ending the HIV Epidemic in the US (EHE) initiative includes a goal to increase РгЕР implementation and aims to decrease new HIV infections 90% by 2030." It also has an overarching goal to achieve HIV-related health equity with increased implementation of prevention services for disproportionately affected US populations.
The PrEP-to-diagnosis ratio (PDR) is the number of persons prescribed PrEP in a given year for each new HIV diagnosis in the previous year, and it is useful to monitor trends in PrEP use among persons in groups who might benefit · It is an easily calculated measure that can be stratified by demographic characteristics to help increase understanding of PrEP inequities." In this report, we calculated PDRs to understand PrEP use by women.
METHODS
We used the IQVIA Real-World Data- Longitudinal Prescription Database (IQVIA) and the National HIV Surveillance System (NHSS) to calculate PDRs in 50 states; Washington, DC; and Puerto Rico. We calculated annual PDRs by dividing the number of persons aged 16 years or older who were prescribed PrEP in IQVIA by the number of diagnosed HIV infections in the previous year in NHSS.
We calculated PDRs stratified by year and sex for the United States. We calculated PDRs for US women by age group and geographic location during 2017 to 2023. We also calculated PDRs for women by state; Washington, ОС; and Puerto Rico in 2023 and for the 20 US counties with the highest number of HIV diagnoses among women in 2022. For the 10 counties with the highest PDRs, we reviewed 2022 annual progress reports by health department recipients of the programmatic CDC cooperative agreement "PS20-2010: Integrated HIV Programs for Health Departments to Support Ending the HIV Epidemic in the United States" and summarized РгЕР activities for women."
RESULTS
The overall PDR increased from 3.9 in 2017 to 13.3 in 2023, indicating that
an increasing number of persons were prescribed РгЕР compared with persons with diagnosed HIV. The PDR among men increased from 4.5 to 15.0 and among women from 1.5 to 5.8 (Appendix Figure A, available as a supplement
to the online version of this article at https://ajph.org).
Among women in 2023, the PDR was highest for those aged 16 to 24 years (8.2) and aged 25 to 34 years (7.1) and was higher in the Northeast (7.3) and West (7.0) compared with the South (5.1) and Midwest (5.6; Table 1). By state, PDRs ranged from 14.7 in Oregon to 0.1 in Puerto Rico (Appendix Table A). Among the 17 US Southern states and Washington, DC, 14 (82%) had PDRs less than the national state median PDR for women of 6.0.
Among the 20 counties with the highest number of women with diagnosed HIV in 2023, PDRs ranged from 2.2 in Dallas County, Texas, to 13.4 in Broward County, Florida, and 16.9 in Miami-Dade County, Florida (Appendix Table B). Health departments in the 10 counties with the highest PDRs reported several programmatic activities focused on women in their annual progress reports (Appendix Table С).8 These activities included PrEP academic detailing of women's health care providers, PrEP promotion in the community, social media campaigns, РГЕР navigation, and PrEP initiation for women who were incarcerated and scheduled for release.
DISCUSSION
PrEP uptake among women has been persistently low in the United States. Among counties with the highest numbers of women with diagnosed HIV infection, PDRs ranged widely, suggesting that some jurisdictions were more successful than others with PrEP implementation for women. Activities conducted by health departments in the 10 counties with the highest PDRs might have contributed to successful PrEP implementation because these counties implemented PrEP activities and service models specifically designed for women. Academic detailing of women's health care providers entailed PrEP experts meeting with individual providers to promote key PrEP messages and to distribute support materials for prescribing PrEP.·? In addition to health department activities in Florida, starting in 2018, Florida provided free PrEP medication in all 67 counties and currently supports the use of PrEP medication assistance programs. '91 Navigation service models designed specifically for women coordinate and support PrEP care including to obtain financial access, schedule and attend clinical appointments, and adhere to and persist with PrEP 212 Social media and other community educational campaigns focus on increasing Black women's awareness of PrEP.®
Although persistent disparities in РгЕР use among racial and ethnic groups are documented," we could not calculate PDRs for women stratified by race and ethnicity because of substantial missing race and ethnicity information in IQVIA data. However, the disproportionate number of HIV diagnoses among Black women underscores that this population is a priority for PrEP implementation. PrEP is a lifesaving biomedical intervention, and its use must be equitable for all disproportionately affected groups, including Black women. Women's use of PrEP empowers them to prevent HIV acquisition regardless of their partners' HIV status or viral suppression. Furthermore, every HIV infection prevented averts a lifetime illness and saves approximately $500 000 for the cost of lifetime treatment. ">
Women encounter many barriers to PrEP use.'·1> A key challenge is identifying women who might benefit from PrEP. It was estimated that 177 000 US women had a PrEP indication in 2015,'° but the US population includes more than 135 million women aged 15 years and older. Clinical encounters provide opportunities for PrEP implementation, yet few women were prescribed PrEP when they presented with objective clinical indications such as a sexually transmitted infection.'7'3 At provider visits, women with indications for PrEP could be identified with clinical decision supports that use information in their electronic health record such as sexually transmitted infections or nonoccupational postexposure prophylaxis prescriptions.
Providing more choice in PrEP modalities could increase PrEP use by both men and women. Three PrEP modalities have been proven effective for women: a daily oral pill, a bimonthly injection, and a semiannual injection. "229 Additional PrEP modalities in development include a long-acting pill and an implantable device. Research is needed to understand preferences for multipurpose prevention technologies with formulations or strategies designed for combined PrEP and contraception. Research is also needed to develop and evaluate interventions to support PrEP initiation, adherence, and persistence and to identify the best implementation strategies for women, especially Black women.
Limitations
This analysis has 3 limitations. First, IQVIA data were missing race and ethnicity information for two thirds of persons prescribed PrEP, preventing accurate determination of PrEP use by race and ethnicity. Second, IQVIA data do not include information about gender identity, so the sex of transgender persons prescribed PrEP might have been misclassified. Third, PDRs could not be calculated by HIV transmission group. Although NHSS data included information about the transmission group, IQVIA data did not.
Public Health Implications
Despite marked increases in PrEP use in the United States during the more than 12 years since its US Food and Drug Administration approval in 2012, PrEP uptake has been substantially lower among women compared with men. PrEP implementation strategies that are designed specifically for women can be effective to increase use.
The goals of EHE will be achieved by preventing HIV acquisition among all persons through increased HIV testing, PrEP use, and sustained viral suppression among persons with HIV. AJPH
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