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. Author manuscript; available in PMC: 2019 Dec 1.
Published in final edited form as: Ann Epidemiol. 2018 May 26;28(12):858–864. doi: 10.1016/j.annepidem.2018.05.006

Location Location Location: An Exploration of Disparities in Access to Publicly Listed PrEP Clinics in the United States

Aaron J Siegler 1, Anna Bratcher 1, Kevin M Weiss 1, Farah Mouhanna 1, Lauren Ahlschlager 1, Patrick S Sullivan 1
PMCID: PMC6261794  NIHMSID: NIHMS971008  PMID: 30406756

Abstract

Purpose

HIV pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV transmission. Finding a PrEP provider, however, can be a barrier to accessing care. This study explores the distribution of publicly listed PrEP-providing clinics in the United States.

Methods

Data regarding 2,094 PrEP-providing clinics come from PrEP Locator, a national database of PrEP-providing clinics. We compared the distribution of these PrEP clinics to the distribution of new HIV diagnoses within various geographical areas and by key populations.

Results

Most (43/50) states had <1 PrEP-providing clinic per 100,000 population. Among states, the median was two clinics per 1,000 PrEP-eligible MSM. Differences between disease burden and service provision were seen for counties with higher proportions of their residents living in poverty, lacking health insurance, identifying as African American, or identifying as Hispanic/Latino. The Southern region accounted for over half of all new HIV diagnoses, but only one-quarter of PrEP-providing clinics.

Conclusions

The current number of PrEP-providing clinics is not sufficient to meet needs. Additionally, PrEP-providing clinics are unevenly distributed compared to disease burden, with poor coverage in the Southern divisions and areas with higher poverty, uninsured, and larger minority populations. PrEP services should be expanded and targeted to address disparities.

Keywords: Pre-Exposure Prophylaxis, HIV, Primary Prevention

Introduction

PrEP is highly effective in preventing HIV transmission.(1) PrEP is indicated by the US Centers for Disease Control and Prevention (CDC) for men who have sex with men (MSM), heterosexual men and women, and people who inject drugs.(2) PrEP is effective in preventing HIV across different populations, with a meta-analysis finding a 70% reduction in HIV infection risk among groups with high (>70%) PrEP adherence.(3) Individuals in an integrated healthcare system who had initiated and remained on PrEP had no HIV seroconversions in 850 person-years of accumulated follow-up time, however, two seroconversions occurred among individuals who had discontinued PrEP.(4)

PrEP initiations have grown rapidly in the United States. From 2012 to 2015, there was a 6.9 fold increase in individuals initiating PrEP regimens.(5) In the 2015 National HIV/AIDS Strategy, the states of New York and Washington were highlighted for their “End AIDS” programs, both of which facilitate access to PrEP.(6) Currently, dozens of other states and cities have projects, specified clinics, and programs that are dedicated to providing PrEP.(7) Despite these efforts, PrEP uptake remains low compared to estimated need. CDC estimates that one-quarter of all MSM are eligible for PrEP,(2) yet survey data indicate that uptake is around 4%.(8)

One barrier to PrEP uptake is the need to find an appropriate provider. All providers who meet standard prescriptive authority rules can prescribe PrEP, but not all providers are willing. A qualitative exploration found rationales of providers for not prescribing PrEP to include concerns regarding poor adherence, toxicity, and the potential for generation of drug-resistance.(9) Other providers may be unaware of PrEP (10, 11) or have concerns regarding cost.(12) Providers who have experience treating patients living with HIV, have previously prescribed post-exposure prophylaxis (PEP), or are part of a larger practice group were more willing to prescribe PrEP.(10, 13) These attributes may increase the likelihood of a physician prescribing PrEP due to increased familiarity with prescribing antiretroviral medication. Similarly, the PrEP ‘purview paradox’ notes that primary care physicians view PrEP antiretroviral regimens and adherence issues as the domain of HIV care specialists, and HIV care specialists are less likely to see the HIV-negative patients who would be eligible for PrEP.(14)

In the short time that tenofovir disoproxil fumarate (TDF/FTC) has been indicated for PrEP by the US Food and Drug Administration, racial disparities in PrEP uptake have developed. For instance, 44% of new HIV diagnoses in 2014 were among African Americans, yet only 10% of individuals initiating PrEP that year were African American.(15) Twenty-three percent of new HIV diagnoses in 2014 were among Hispanic Americans, yet only 12% of individuals initiating PrEP were Hispanic. Reasons for disparities are likely multifactoral, with diverse contributors such as social stigma, medical mistrust, financial barriers, and awareness. (16, 17) Medical students in one study were more likely to expect sexual risk compensation in African American patients than white patients; these beliefs indirectly reduced willingness to prescribe PrEP to African American patients.(18)

Given hesitancy or unwillingness to prescribe PrEP by some clinicians, and in light of racial disparities in PrEP use, it is critical to minimize known barriers to accessing PrEP. Minorities and individuals with lower incomes are more likely to face geographic barriers to accessing healthcare.(19) Geographic availability has been shown to impact access to HIV care and may also be critical to PrEP access.(20) Proximity of providers may be particularly important because individuals on PrEP are recommended by CDC to have four clinician visits each year.(21) Using data from PrEP Locator, a national database of publicly-listed clinics that prescribe PrEP, we describe the geographic distribution of PrEP clinics in the United States. This county-level analysis explores how the density of PrEP-providing clinics aligns with race, income, insurance status, and urbanicity in comparison to the overall population, to estimated numbers of MSM eligible for PrEP, and to new HIV diagnoses.

Methods

Data regarding PrEP-providing clinics come from PrEP Locator, a national and publicly-available database of clinics developed by the authors.(22, 23) The PrEP Locator database was developed from over 50 different data sources, including all available state health department directories, local health department directories, non-governmental organization directories, and HIV-related medical organization member surveys. To be eligible for inclusion, all clinics in the database were determined to have a working phone number, have personnel at that phone number confirm that the clinic prescribes PrEP, and have a clinician with appropriate licensure to prescribe PrEP determined by state licensure databases. Clinic eligibility was assessed through phone calls by Emory staff. Nonresponsive clinics, having not responded to a minimum of three calls, were excluded from the database. Updates to the database occurred through opt-in suggestions to add or update provider information through a public webform, or through collaborations with state and local directories to update database information on a regular basis. Proposed updates to the database are placed in a holding pen, which is then vetted by Emory staff prior to release. Further documentation regarding the development and procedures of PrEP Locator are available.(22) Data for the present analysis were extracted from the Locator database in February 2018.

County- and state-level data for age, gender, the proportion of residents living in poverty, and the proportion of residents uninsured were obtained from the US Census Bureau. Poverty is defined as three times the cost of a minimum food diet(24) and uninsured is defined as individuals not covered by any type of private or government insurance for any part of the previous year.(25) Geographic regions were categorized into nine divisions according to standard US Census Bureau divisions. To explore possible racial disparities in the distribution of PrEP clinics, we used race/ethnicity estimates: for state-level data we used the year 2016 American Community Survey of the US Census Bureau (ACS), and for county-specific data we used the four year 2012–2016 ACS. We ranked counties by the proportion within each county that identified as African American race or Hispanic ethnicity (inclusive of all races), and categorized the data as <5%, 5 – <10%, 10 – <20%, and ≥ 20% of each race/ethnicity. Counties were also ranked based on the proportion of residents living in poverty and the proportion of residents uninsured into categories of <10%, 10 – <15%, 15 – <20%, and ≥ 20%. These cut points were chosen to provide meaningful intervals, guided by histograms of each variable’s distribution. Urbanicity classification was based on the National Center for Health Statistics (NCHS) Urban-Rural Classification Scheme.

New HIV diagnoses and prevalent HIV cases from 2016 are from the AIDSVu database,(26) which uses data from the CDC National HIV Surveillance System (NHSS) for county-level data. The NHSS is a database of HIV/AIDS diagnosis surveillance conducted by state or territory health departments according to uniform surveillance case definitions and case report forms, with data then provided to CDC. In the AIDSVu dataset, geographic areas with either small numerator (HIV diagnosis or prevalent case numbers < 5) or small denominator (number of people in a particular population < 100) data are suppressed to protect identity. We estimated values for counties with suppressed data by subtracting, for each state, all known county-level values of HIV diagnoses from the state total. The remainder (the total from unknown counties) was distributed evenly to counties with missing data. To assess HIV diagnoses in urban areas, we included county-level diagnosis data for 33 cities in the AIDSVu database. AIDSVu obtains these data directly from state and local health departments. City limits for this analysis were defined by core-based statistical areas (CBSAs). We estimated the number of PrEP-eligible MSM in each state and city using small-area population estimates for MSM multiplied by the CDC-estimated proportion of MSM indicated for PrEP (24.7%). (27) MSM population estimates were calculated based on previously published methods, here replicated based on current 2016 US Census data. (28, 29) In brief, this estimation method uses the National Health and Nutrition Examination Survey (NHANES) and urbanicity-stratified weights derived from ACS to estimate population counts for the number of MSM in each county in the United States.

We calculated the number, and percent of national total, of PrEP-providing clinics in US Census Divisions (excluding Puerto Rico). The numbers of PrEP clinics are also displayed for groups of counties ranked by urbanicity, proportion of residents living in poverty or uninsured, and concentration of the population African American or Hispanic (Table 1). Ratios of PrEP clinics divided by new HIV diagnoses were calculated at the county level, and are shown in Table 1 to explore the distribution of PrEP clinics relative to epidemic need. Tables 2 and 3 provide state- and city-level data on the number of PrEP clinics in geographic areas. We calculated clinic prevalence (clinics per 100,000 population over 13 years of age), ratios of clinics per 1,000 PrEP-eligible MSM, and ratios of clinics per 1,000 new HIV diagnoses for each area. Clinic prevalence is calculated to allow for assessment of the number of clinics relative to the population size for each geographic area. Ratios of clinics per PrEP-eligible MSM are used to compare the number of clinics relative to the number of individuals indicated for the service. Ratios of clinics to new HIV diagnoses are used to compare the number of clinics to epidemic need. The dataset may not contain all publicly-listed PrEP clinics. It is, however, the only nationally available method to find PrEP-providing clinics and it includes data from all other major listings of PrEP clinics such as health departments and medical organizations. Therefore, we believe the data approximate a census of clinics that an individual seeking PrEP would be able to easily access, so we do not use inferential statistics to generalize to a broader population of clinics, such as statistical significance testing.

Table 1.

Distribution of 2,094 PrEP-Providing Clinics and New HIV Diagnoses in the United States

PrEP-Providing
Clinics, 2018		 PrEP Eligible MSM, 2016 PrEP Need1 New Diagnoses,
2016
N % of
national
total		 N % of
national
total		 Clinics
per
1,000		 N % of
national
total		 Clinics
per 1,000
Census Division
East North Central 260 12 115,444 14 2.3 3,807 10 68.3
East South Central 67 3 37,396 4 1.8 1,991 5 33.7
Middle Atlantic 365 17 87,396 10 4.2 5,168 13 70.6
Mountain 197 9 66,586 8 3.0 2,067 5 95.3
New England 148 7 27,824 3 5.3 1,131 3 130.9
Pacific 485 23 179,799 21 2.7 5,733 14 84.6
South Atlantic 333 16 186,289 22 1.8 12,303 31 27.1
West North Central 100 5 38,928 5 2.6 1,232 3 81.2
West South Central 139 7 110,508 13 1.3 6,222 16 22.3
Urbanicitya (by county)
Large central metro 1,062 51 447,717 53 2.4 20,344 51 52.2
Large fringe metro 381 18 205,695 24 1.9 7,832 20 48.6
Medium metro 370 18 101,172 12 3.7 6,544 17 56.5
Small metro 143 7 39,911 5 3.6 2,072 5 69.0
Micropolitan 88 4 35,431 4 2.5 1,354 3 65.0
Noncore 50 2 20,232 2 2.5 1,506 4 33.2
Poverty (by county)
Less than 10% poverty 273 13 126,253 15 2.2 3,878 10 70.4
10% – <15% poverty 677 32 249,405 29 2.7 9,698 24 69.8
15% – <20%poverty 855 41 379,932 45 2.3 18,864 48 45.3
20% or more poverty 289 14 94,580 11 3.1 7,215 18 40.1
Percent Uninsured (by county)
Less than 10% uninsured 922 44 297,035 35 3.1 9,484 24 97.2
10% – <15% uninsured 793 38 332,874 39 2.4 16,644 42 47.6
15% – <20% uninsured 299 14 157,017 18 1.9 9,232 23 32.4
20% or more uninsured 80 4 63,244 7 1.3 4,294 11 18.6
African American Concentration (by county)
Less than 5% African American 555 27 207,048 24 2.7 5,906 15 94.0
5% – <10% African American 496 24 209,107 25 2.4 7,909 20 62.7
10% – <20% African American 474 23 198,946 23 2.4 10,260 26 46.2
20% or more African American 569 27 235,068 28 2.4 15,579 39 36.5
Hispanic Concentration (by county)
Less than 5% Hispanic 370 18 132,241 16 2.8 6,549 17 56.5
5% – <10% Hispanic 487 23 192,599 23 2.5 8,450 21 57.6
10% – <20% Hispanic 411 20 160,620 19 2.6 7,248 18 56.7
20% or more Hispanic 826 39 364,709 43 2.3 17,408 44 47.4
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1

New HIV diagnoses are considered as an ecological proxy for PrEP need per geographic area

a

Large central metro: greater than 1,000,000 population, central. Large fringe metro: greater than 1,000,000 population, fringe. Medium metro: between 250,000 and 999,999 population. Small metro: between 250,000 and 50,000 population. Micropolitan: between 10,000 and 49,999 population. Noncore: less than 10,000 population.

Table 2.

State-Level Distribution of PrEP-Providing Clinics by Total Population, PrEP Eligible MSM and New HIV Diagnoses

PrEP-Providing Clinics
N per
State		 Population1 N per
100,000
Population		 PrEP-
Eligible
MSM
Population		 N per 1,000
PrEP
Eligible
MSM		 New HIV
Diagnoses2 		N per 1,000
New HIV
Diagnoses
Alabama 10 4,082,821 0.2 7,928 1.3 533 18.8
Alaska 8 605,097 1.3 1,637 4.9 37 216.2
Arizona 47 5,761,526 0.8 20,500 2.3 778 60.4
Arkansas 7 2,479,841 0.3 3,653 1.9 314 22.3
California 322 32,715,033 1.0 134,968 2.4 4,961 64.9
Colorado 89 4,632,086 1.9 20,685 4.3 423 210.4
Connecticut 43 3,056,129 1.4 5,891 7.3 251 171.3
Delaware 8 806,543 1.0 2,449 3.3 117 68.4
Florida 139 17,661,830 0.8 77,093 1.8 4,940 28.1
Georgia 33 8,521,448 0.4 26,781 1.2 2,709 12.2
Hawaii 7 1,201,433 0.6 3,958 1.8 82 85.4
Idaho 7 1,369,530 0.5 3,058 2.3 44 159.1
Illinois 90 10,726,317 0.8 40,942 2.2 1,384 65.0
Indiana 33 5,506,076 0.6 13,537 2.4 483 68.3
Iowa 10 2,611,034 0.4 2,985 3.4 133 75.2
Kansas 17 2,389,068 0.7 3,577 4.8 141 120.6
Kentucky 17 3,714,599 0.5 9,486 1.8 319 53.3
Louisiana 33 3,878,595 0.9 9,404 3.5 1,151 28.7
Maine 25 1,151,311 2.2 2,371 10.5 50 500.0
Maryland 37 5,052,126 0.7 16,133 2.3 1,097 33.7
Massachusetts 54 5,845,108 0.9 13,198 4.1 710 76.1
Michigan 47 8,385,984 0.6 21,417 2.2 747 62.9
Minnesota 29 4,588,522 0.6 15,342 1.9 286 101.4
Mississippi 10 2,471,502 0.4 3,434 2.9 424 23.6
Missouri 31 5,101,456 0.6 13,653 2.3 511 60.7
Montana 6 878,537 0.7 2,106 2.9 17 352.9
Nebraska 5 1,562,564 0.3 1,857 2.7 76 65.8
Nevada 21 2,452,586 0.9 8,260 2.5 525 40.0
New Hampshire 9 1,152,702 0.8 2,011 4.5 42 214.3
New Jersey 44 7,537,589 0.6 15,496 2.8 1,143 38.5
New Mexico 17 1,733,137 1.0 5,317 3.2 125 136.0
New Y ork 255 16,745,354 1.5 49,896 5.1 2,875 88.7
North Carolina 52 8,513,324 0.6 22,582 2.3 1,404 37.0
North Dakota 5 626,443 0.8 765 6.5 46 108.7
Ohio 69 9,765,669 0.7 29,147 2.4 969 71.2
Oklahoma 8 3,225,510 0.3 7,894 1.0 293 27.3
Oregon 22 3,471,843 0.6 14,124 1.6 221 99.6
Pennsylvania 66 10,888,756 0.6 22,004 3.0 1,150 57.4
Rhode Island 2 912,171 0.2 3,239 0.6 70 28.6
South Carolina 13 4,172,373 0.3 6,781 1.9 757 17.2
South Dakota 2 707,973 0.3 749 2.7 39 51.3
Tennessee 30 5,576,555 0.5 16,548 1.8 715 42.0
Texas 91 22,593,541 0.4 89,558 1.0 4,464 20.4
Utah 10 2,377,712 0.4 5,670 1.8 135 74.1
Vermont 15 540,664 2.8 1,113 13.5 8 1,875.0
Virginia 24 7,070,310 0.3 23,152 1.0 893 26.9
Washington 126 6,106,317 2.1 25,111 5.0 432 291.7
West Virginia 9 1,562,558 0.6 2,665 3.4 66 136.4
Wisconsin 20 4,865,079 0.4 10,400 1.9 224 89.3
Wyoming 2 481,302 0.4 989 2.0 20 100.0
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1

Population counts include only persons at least 13 years of age.

2

New HIV diagnoses are considered as an ecological proxy for PrEP need per geographic area

Table 3.

Distribution of 996 PrEP-Providing Clinics in Cities in the United States, by Total Population, Eligible MSM and New Diagnoses

PrEP-Providing Clinics
City1 N
per
City		 Population2 N per
100,000
Population		 PrEP-
Eligible
MSM
Population		 N per
1,000 PrEP
Eligible
MSM		 New HIV
Diagnoses3 		N per 1,000
New HIV
Diagnoses
Atlanta, Georgia 25 4,592,379 0.5 21,588 1.2 1,722 14.5
Austin, Texas 9 1,596,561 0.6 11,167 0.8 308 29.2
Baltimore, Maryland 26 2,336,010 1.1 9,054 2.9 531 49.0
Baton Rouge, Louisiana 5 682,542 0.7 1,076 4.6 250 20.0
Birmingham, Alabama 2 950,171 0.2 3,717 0.5 106 19.0
Bridgeport Areaa, Connecticut 13 786,439 1.7 1,142 11.4 72 180.6
Charlotte, North Carolina 16 1,960,643 0.8 8,777 1.8 399 40.1
Chicago, Illinois 80 7,913,514 1.0 37,347 2.1 1,255 63.8
Columbia, South Carolina 5 671,446 0.7 1,191 4.2 178 28.1
Dallas, Texas 27 5,607,813 0.5 32,245 0.8 1,341 20.1
Denver, Colorado 48 2,275,974 2.1 16,145 3.0 302 159.1
Detroit, Michigan 25 3,605,463 0.7 12,684 2.0 504 49.6
Hartford, Connecticut 13 1,036,214 1.3 2,806 4.6 72 181.8
Houston, Texas 45 5,203,917 0.9 26,238 1.7 1,467 30.7
Jackson, Mississippi 1 134,485 0.7 183 5.5 11 90.9
Jacksonville, Florida 6 1,190,311 0.5 5,162 1.2 337 17.8
Las Vegas, Nevada 19 1,712,020 1.1 6,767 2.8 470 40.4
Memphis, Tennessee 13 1,096,682 1.2 5,647 2.3 303 42.9
Miami Areab, Florida 59 5,050,905 1.2 29,762 2.0 2,342 25.2
Milwaukee, Wisconsin 9 1,304,605 0.7 5,533 1.6 117 76.9
Nashville, Tennessee 6 1,484,647 0.4 6,793 0.9 187 32.1
New Haven Areac, Connecticut 10 734,856 1.4 1,099 9.1 81 123.5
New Orleans, Louisiana 21 1,045,421 2.0 5,055 4.2 422 49.8
New York City Aread, New York 200 16,859,126 1.2 50,878 3.9 3,401 58.8
Norfolk Areae, Virginia 5 1,433,906 0.3 5,421 0.9 298 16.8
Orlando, Florida 35 1,957,263 1.8 12,226 2.9 664 52.7
Philadelphia, Pennsylvania 46 5,086,489 0.9 11,700 3.9 793 58.0
Raleigh, North Carolina 11 1,019,379 1.1 4,942 2.2 189 58.3
Richmond, Virginia 6 1,058,667 0.6 3,888 1.5 181 33.1
San Francisco Areaf, California 82 3,897,873 2.1 29,413 2.8 739 111.0
Seattle, Washington 82 3,080,373 2.7 16,941 4.8 314 261.1
Tampa, Florida 13 2,500,138 0.5 17,143 0.8 559 23.3
Washington, D.C.g 33 4,990,502 0.7 25,579 1.3 1,110 29.7
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1

Defined by core based statistical areas

2

Population counts include only persons at least 13 years of age

3

New HIV diagnoses are considered as an ecological proxy for PrEP need per geographic area

a

Bridgeport-Stamford-Norwalk CBSA

b

Miami-Fort Lauderdale-West Palm Beach CBSA

c

New Haven-Milford CBSA

d

New York City-Newark CBSA

e

Norfolk-Virginia Beach-Hampton Roads CBSA

f

San Francisco-Oakland-Alameda CBSA

g

Washington-Arlington-Alexandria, CBSA

Figures 1a and 1b geographically present state-level data. Figure 1a displays clinic prevalence for each state, with states grouped by quintile (groups of 10 states) from least to greatest PrEP clinic prevalence. Figure 1b displays the ratio of clinics per 1,000 new HIV diagnosis in each state, with states grouped by quintile from least to greatest values.

Figure 1.

Figure 1

Figure 1

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a. The proportion of PrEP-providing clinics per PrEP-eligible MSM by state, ranked by quintile 2018

b. The proportion of PrEP-providing clinics per new HIV diagnoses by state, ranked by quintile, 2018

Results

There were 2,094 publicly listed, PrEP-providing clinics in the United States (Table 1). Relative to need, estimated through concentration of new HIV diagnoses, Southern census divisions had fewer than expected PrEP clinics. Southern census divisions of the United States had lower ratios of PrEP-providing clinics to new HIV diagnoses than census divisions in other regions. For instance, the South Atlantic Division had 15.9% of all publicly listed PrEP clinics and 31.0% of all new HIV diagnoses. The Southern region, comprising all Southern census divisions (East South Central, West South Central, and South Atlantic), accounted for 51.7% of all new HIV diagnoses, but only 25.7% of PrEP-providing clinics. Analysis of counties, grouped by demographic characteristics, revealed disparities in the proportion of clinics relative to the number of new HIV diagnoses. Counties with ≥20% of the population living in poverty had 13.8% of PrEP-providing clinics, and 18.2% of new HIV diagnoses. Counties with ≥20% of the population lacking health insurance had 3.8% of clinics and 10.8% of new HIV diagnoses. Counties with ≥20% identifying as African American had 27.2% of PrEP-providing clinics and 39.3% of new HIV diagnoses.

PrEP-providing clinic prevalence (clinics per overall population), ratios of clinics per PrEP-eligible MSM, and ratios of clinics per new HIV diagnoses were low across states (Table 2). 43/50 states had <1 PrEP-providing clinic per 100,000 population, 1/50 states had <1 clinic per 1,000 PrEP-eligible MSM, and 35/50 states had <100 clinics per 1,000 new HIV diagnoses. No state had >3 PrEP-providing clinics per 100,000 population or >14 clinics per 1,000 PrEP eligible MSM.

There was substantial variation in the availability of PrEP across states. The median ratio of PrEP clinics per 100,000 overall population was 0.6 among all states, with a range that spanned over an order of magnitude (0.2 to 2.8). The median ratio of PrEP clinics per 1,000 PrEP-eligible MSM was 2.4 (range, 0.6 to 13.5). The median was ratio of PrEP clinics per new 1,000 new HIV diagnoses was 67.1, with a range that spanned over two orders of magnitude (12.2 to 1,875.0).

State-level geographic distributions of PrEP-providing clinics are displayed using a denominator of population in Figure 1a and a denominator of new HIV diagnoses in Figure 1b. The different denominators allow for a view of the level of PrEP-providing clinics per population (Figure 1a) and per epidemic need (Figure 1b). PrEP-providing clinic ratios per PrEP-eligible MSM and per new 1,000 HIV diagnoses were higher in the New England, Middle Atlantic, and Mountain districts of the United States and lower in the West South Central, East South Central, and South Atlantic districts (Figure 1). Analysis of city-level data reveal similar trends (Table 3). PrEP availability is lower in the Southern cities of Birmingham (19.0 clinics / 1000 new diagnoses), Atlanta (14.5/1000), and Jacksonville (17.8/1000) than in the Northeast cities of Philadelphia (58.8/1000) and New York (58.8/1000) or than in the Northwest cities of San Francisco (111.0/1000) and Seattle (261.1/1000).

Discussion

This study of publicly listed PrEP-providing clinics in the United States provides a geographic depiction of the availability of PrEP. PrEP-providing clinics were rare, with more than half of states having <3 PrEP-providing clinics per 1,000 PrEP-eligible MSM. For even a moderate proportion of MSM eligible for PrEP to be able to initiate care, the availability of PrEP-providing clinics will need to increase. To have optimal impact, PrEP coverage will need to be high; modeling indicates that 40% PrEP coverage among eligible MSM could prevent 33% of new HIV infections, with diminishing impact at lower coverage levels.(30) To achieve such levels of PrEP scale-up, new strategies are needed to increase access to PrEP.

Within the United States, several disparities in PrEP access emerge in this county-level analysis, including different numbers of clinics compared to region, income, ethnicity, and insurance status. The direction of the disparities contradicts need, with population groups with higher levels of HIV transmission having less access to PrEP services. Southern states, areas of lower income, areas with higher African American and Hispanic populations, and areas with less insurance coverage all represent areas disproportionately impacted by new HIV diagnoses,(31) and are conversely under-represented in PrEP clinic density. If not addressed, PrEP geographic and other access disparities may be sufficient to exacerbate existing disparities in the overall HIV epidemic in the United States. Therefore, there is a need to develop new strategies to make PrEP accessible not only more broadly, but also to those groups most at-risk who currently experience lower levels of access to health services.

PrEP is a new HIV intervention approved by the U.S. Food and Drug Administration (FDA) in 2012, and the existence of 2,094 publicly listed PrEP-providing clinics in the United States is a noteworthy public health accomplishment. In our dataset, it is clear that local investments in PrEP have an impact in terms of access. Public health authorities in cities such as Seattle(32) and New York(33) have made concerted efforts to increase the number of publicly-listed PrEP-providing clinics, and the success of these efforts can be seen in the geographic distribution of clinics. Similarly, public health officials and groups in North Carolina have made successful outreach efforts to increase the number of local PrEP-providing clinics,(34) resulting in the state being an outlier to the trend of Southern states housing fewer PrEP providers. Localities also have the potential to alleviate disparities in PrEP provision due to income or insurance coverage by funding PrEP drug assistance and navigation programs that can facilitate increased PrEP access. These public health investments in PrEP yield clear benefits, and should be continued and expanded.

This study has a number of limitations. Clinics included in the dataset, coming from PrEP Locator, do not comprise all clinicians prescribing PrEP in the United States. Instead, clinics are those that were publicly listed and identified through an extensive search and vetting process. This results in underestimating the availability of PrEP-providing clinics. Yet, a substantial proportion (72% in one study)(35) of primary care providers had low familiarity with prescribing PrEP, so many patients seeking PrEP will be limited to publicly-listed PrEP clinics such as those in this study’s dataset. Using new HIV diagnoses from 2016, compared to PrEP clinic data from 2018, might introduce misclassification of characteristics of states, counties, or cities. Notably, CDC has recently indicated that new diagnoses decreased from 2008–2013 in the United States.(36) Ratios of PrEP-providing clinics to new HIV diagnoses may therefore be underestimated, although relative comparisons are likely still valid. Another limitation is that this analysis does not take into account clinic size. However, having fewer PrEP clinics overall, even if some may be larger or smaller, still likely serves as a barrier to seeking care. Last, access to a PrEP provider is not the sole barrier to PrEP use. An adequate distribution of PrEP-providing clinics would still not be sufficient to overcome other racial and economic disparities in PrEP access.(37, 38)

In the six years since the indication of TVD-FTC for PrEP by FDA, over 2,000 clinics have publicly listed themselves as providing PrEP. Despite this success, there is insufficient PrEP clinic availability, and local availability is in contradiction of need. Alternative models of PrEP provision may facilitate access, including provision of PrEP at pharmacies, federally qualified healthcare centers, and through telemedicine.(39, 40) Interventions to address disparities should also include structural interventions, such as Florida’s use of county-health clinics to provide PrEP at no-cost.(41) Such innovative programs and policies have the promise to decrease disparities in PrEP access, and to support continuation of the overall expansion of PrEP as a highly effective HIV prevention strategy.

Acknowledgments

Funding

Support for development of the PrEP Locator was provided by the MAC AIDS Fund. The study was facilitated by the Emory Center for AIDS Research P30AI050409 and by R01MH114692. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

List of Abbreviations and Acronyms

ACS

American Community Survey

CBSA

Core-Based Statistical Areas

CDC

U.S. Centers for Disease Control and Prevention

FDA

U.S. Food and Drug Administration

MSM

Men Who Have Sex with Men

NCHS

National Center for Health Statistics

NHSS

National HIV Surveillance System

PEP

Post-Exposure Prophylaxis

PrEP

HIV Pre-Exposure Prophylaxis

Footnotes

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