CHERISH Pilot Grantee Highlight Low PrEP Use Among Women
Researchers call for tailored strategies to engage women in HIV prevention care.
The introduction of pre-exposure prophylaxis (PrEP) for HIV prevention has been paramount to reducing HIV transmission and improving the lives of people living with HIV. However, trends in HIV cases and PrEP uptake suggest unaddressed opportunities to reach women and other communities at risk of contracting HIV.
Cis-gender women represent 20% of new HIV cases each year (with Black/African American women accounting for half of those cases), but make up less than 10% of people who use PrEP. Studies also find that Black women and those with low incomes have a high need for PrEP but their usage has been low.
Existing studies look to Medicaid policies and family planning clinics as opportunities to engage women in HIV care. Insured individuals are more likely to use PrEP, compared to uninsured individuals, and for nearly 40% of women in the U.S., family planning services are their sole form of healthcare.
Two new analyses, supported by a CHERISH pilot grant awarded to Dion Allen in 2022, seek to examine how state Medicaid expansion and the availability of healthcare facilities impact PrEP uptake among women using a need-based measure. Understanding the role of Medicaid and healthcare settings can inform strategies for tailoring PrEP-related care for women.
Dion Allen, PhD, MSc
Dion Allen is a health outcomes researcher and currently a postdoctoral associate at the University of Miami Miller School of Medicine.
Association of Medicaid Expansions on PrEP Uptake
States that expanded Medicaid programs saw increased PrEP use for the general state population, though tailored strategies are needed to increase PrEP uptake among women.
Medicaid expansion under the Affordable Care Act allowed for greater coverage of health services, including lowering the cost to prescribe and obtain PrEP. Allen and colleagues sought to examine the impact of these expansions on PrEP uptake across social and demographic factors to assess whether Medicaid provisions can increase PrEP use among women in greatest need of it.
Using publicly available data from 2012-2021, sourced from AIDSVu and the Kaiser Family Foundation database, the team employed a difference-in-differences regression model, calculated the PrEP rate and PrEP-to-need ratio, a measure of need that takes into account recent HIV-infections in a population, for individuals aged 13 and older, and stratified the rates by geography, sex assigned at birth, and state.
Key Findings
- The study revealed that Medicaid expansions were associated with better PrEP outcomes overall, with increases of 19% in PrEP rate and 40% in PrEP-to-need ratio for every state that expanded Medicaid.
- Males experienced better outcomes with a 43% increase in PrEP-to-need ratio, while females saw a 16% increase that was not statistically significant.
The study identified significant improvements in PrEP uptake among men and modest increases among women. However, researchers emphasize the need to improve PrEP uptake among women and women across race and low-income groups. This study also uniquely contributes to the literature by accounting for need-based measures, longer timeframe, and demographics like geography, marital status, education, and sex assigned at birth. Further research can examine effective and cost-effective strategies to identify and engage women who can benefit from HIV prevention care, such as through state-wide interventions that complement Medicaid expansions or initiatives that tailor to women’s health needs and barriers to care.
Impact of Mental Health and Substance Use Disorder Treatment, and Family Planning Clinics’ Availability on PrEP Uptake
The availability of treatment and family planning clinics showed no effect or a negative relationship on PrEP uptake for women, suggesting a missed opportunity.
Mental health and substance use disorder (SUD) treatment, and family planning clinics have the potential to connect women and women who inject drugs to HIV prevention services. Lead author Allen and colleagues sought to estimate the impact of the availability of those facilities on PrEP rate and PrEP-to-need ratio for women across all 50 states.
The team used state-level data from 2012-2021, sourced from AIDSVu, County Business Patterns, Integrated Public Use Microdata Series, and Current Population Survey, to generate a difference-in-differences regression model looking at the relationship between availability of the clinics and PrEP uptake for men and women aged 13 and older.
Key Findings
- Findings demonstrate a small positive association between the availability of mental health and SUD treatment centers and PrEP rate for men, but not for women.
- The availability of family planning clinics was associated with an 8% decrease in PrEP rate among females.
The authors conclude that the negative association on PrEP rate and the zero effect on PrEP-to-need ratio for women indicate that PrEP is not adequately implemented in mental health and SUD treatment settings, and family planning clinics. While the findings did not support a positive relationship on PrEP uptake, the study serves as a foundation for future implementation research examining ways to increase PrEP use among women. Existing studies also support integrating PrEP into routine care and creating a healthcare environment that normalizes offering PrEP to all women.
The two studies featuring lead author Dion Allen and CHERISH Research Affiliate Ioana Popovici are, “What Is the Effect of Medicaid Expansions on Preexposure Prophylaxis for HIV Prevention Use among Women?”, published in AIDS and Behavior in July 2025, and, “Using epidemiological data to explore the impact of mental health and substance use disorder treatment facilities and family planning clinic availability on pre-exposure prophylaxis use for women in the U.S.”, published in AIDS Care in August 2025. These studies are supported, in part, by a CHERISH pilot grant awarded to Allen.