HIV prevention treatment rising among young adults, U-M study finds

• Americans aged 18 to 25 have increased their use of pre-exposure prophylaxis, or PrEP, in the last decade, according to the study
• Michigan doctors note affordability is often a barrier to the HIV prevention medicine
• PrEP and other preventive treatments are at risk of losing coverage amid ongoing legal challenges to the Affordable Care Act

As the US Supreme Court weighs a decision that could upend how insurers cover preventive-care treatments, researchers at the University of Michigan have found a dramatic rise in young adults taking one of the world’s leading HIV prevention medications.

A study published in the Journal of General Internal Medicine this month found that Americans aged 18 to 25 have increased their use of pre-exposure prophylaxis, or PrEP, in the last decade.

“There's a disproportionate share of new HIV diagnoses in young adults in the United States,” said Dr. Nina Hill, a U-M physician and lead author of the study. “We found that, long story short, dispensing grew very rapidly for that young adult population.”

Hill and her team found the medicine’s dispensing rate rose from about 26 per 100,000 people in 2016 to 208 per 100,000 by 2023 among the population they studied.

What is PrEP?

PrEP is used by people with a greater likelihood of getting HIV who may contract the virus from having sex or injecting drugs. Studies have found the treatment to be highly effective — the US Centers for Disease Control and Prevention reports the medicine, when taken as prescribed, reduces the chance of getting HIV from sex by 99%, and by 74% for people who inject drugs.

In Michigan, there were more than 17,500 people living with HIV in 2022, according to the AIDSVu mapping project, with 629 new diagnoses that year. Male-to-male sexual contact transmission accounts for the majority of cases, with Black and Hispanic/Latino populations disproportionately impacted in the state. People ages of 13 to 34 represent about 23% of Michigan’s total HIV cases.

The U-M study indicates that more PrEP is being dispensed to young adults and more patients are starting up on the medicine. While the data does not explain why the trend has grown in a positive direction, Hill suspects that one reason for the increase is doctors and patients have become more familiar with the treatment as time goes on.

“Being a young adult and navigating the health care system can be really challenging,” she said, adding that initial provider discomfort in prescribing PrEP and patient challenges accessing treatments have likely waned during the time period she studied.

Hill notes that while PrEP intake is trending in the right direction, many obstacles exist to access the treatment. 

“We know that young adults in particular are at higher risk of not having health insurance,” Hill said. “A lot of our patients are experiencing long wait times to get appointments with their doctor, or they have to see someone new that maybe they don't feel comfortable talking about a sensitive topic, like their sexual health.”

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An additional challenge is ensuring patients remain on PrEP by taking it consistently as prescribed, which is often as a single daily dose taken orally. 

Dr. Lauren Snyder, a family medicine doctor at Corewell Health in Grand Rapids with a focus on LGBTQ health, said PrEP has become more accessible as costs come down.

“It's really been the affordability that has been the biggest barrier to my patients,” she said. 

Tenofovir disoproxil fumarate and emtricitabine (TDF/FTC), a PrEP medication originally released by Gilead Sciences as Truvada, came off patent in 2020. Its generic competition helped drive down the medication’s price.  

“The best kind of PrEP is a PrEP you can get consistently,” Snyder said.

To that point, the U-M study found a decline in how long people remain on PrEP after starting the medication. 

Hill says there’s multiple possibilities to explain that trend, including existing restrictions to access and the expansion of PrEP prescriptions to a broader patient population that may be less likely to acquire HIV. Some patients take PrEP “on-demand” before potential exposure, which can lower the number of pills dispensed.

“We see two potentially positive outcomes, which are rising dispensing and rising initiation. And then that third outcome, the persistence was decreasing,” Hill said. “That's the one that raises a little bit of concern for wanting to better understand what's happening there.”

Kennedy v. Braidwood Management

Legal challenges to the Affordable Care Act’s preventive services requirement could stop employers and insurance companies from fully covering PrEP and other treatments like contraceptives, cancer screenings and HPV vaccines.

A group of businesses and individuals, led by the Christian-owned business Braidwood Management, raise a religious objection to covering PrEP, saying it “encourage[s] homosexual behavior, intravenous drug use, and sexual activity outside of marriage between one man and one woman.”

The lawsuit, originally filed in a federal court in Texas in 2020, was argued before the Supreme Court in April. The case focuses on whether the appointment of the US Preventive Services Task Force, the independent panel responsible for recommending PrEP, is constitutional.  Plaintiffs argue the task force’s recommendations can be overridden by the US Health and Human Services secretary, a job currently held by Robert F. Kennedy Jr. 

While a decision on the case is pending, LGBTQ and HIV advocacy groups worry that reducing access to PrEP would jeopardize the safety of Americans.

“The elimination of no-cost preventive care measures like PrEP will force the nation into another HIV outbreak despite the existence of preventive measures proven to minimize communicability,” a national alliance of HIV, LGBTQ and health care organizations wrote in a brief for the case. 

“While decades of bipartisan efforts to decrease the incidence and prevalence of HIV/AIDS and similar public health crises have monumentally improved public welfare, eradication and continued health promotion are contingent on widespread access to preventive care measures.

Michigan doctors like Lauren Snyder worry how the court case could impact continued coverage for PrEP.

The Preventive Services Task Force “puts out recommendations that we know there are really good cost-benefit analyses for and also really good evidence that our patients benefit from,” she said. “My hope is that we're able to continue to follow good science.”