Between 2017 and 2018, use of Truvada (tenofovir disoproxil fumarate/emtricitabine) as pre-exposure prophylaxis (PrEP) in the United States increased by 39%. However, considerable disparities emerged when it came to PrEP use based on sex, age, location, socioeconomic status and access to care.

These findings stem from two studies published in the Annals of Epidemiology, which are being released in conjunction with AIDSVu’s newly updated, highly granular PrEP use infographics that offer the first-ever county-level data on the use of Truvada for HIV prevention in the United States.

In October 2019, the Food and Drug Administration approved a second combination antiretroviral tablet for use as PrEP, Descovy (tenofovir alafenamide/emtricitabine). The new studies looked only at PrEP use through 2018, when Truvada was the sole approved PrEP medication.

Led by Aaron Siegler, PhD, of the Rollins School of Public Health at Emory University in Atlanta, one study found that PrEP use consistently grew from 2012, when Truvada was approved for use as PrEP, through 2018.

Ninety-four percent of U.S. PrEP users in 2018 were men, and 6% were women. Nationally, the PrEP use rate was lowest among those younger than 25, at 52 PrEP users per 100,000 people, and those older than 54, at 16 PrEP users per 100,000 people.

Compared with states that neither expanded Medicaid under the Affordable Care Act (Obamacare) nor provided state residents with a PrEP assistance program to cover the high cost of Truvada, states that had either expanded Medicaid or had an assistance program had a 25% higher rate of PrEP use in 2018. States that both expanded Medicaid and had a PrEP assistance program had a 99% higher rate of PrEP use.

Siegler has established a method of analyzing PrEP use as a reflection of the impact PrEP could theoretically have on local HIV diagnoses. Called the PrEP-to-need ratio, this method divides the number of PrEP prescriptions by the number of annual HIV diagnoses in a particular area.

For each 100,000 residents, U.S. counties that had the highest proportion of Black residents in 2018 had 88 PrEP users and a PrEP-to-need ratio of 3.4 (meaning 3.4 PrEP users for each HIV diagnosis in those counties). By comparison, the PrEP use rate was 41 per 100,000 residents, and the PrEP-to-need ratio was 7.6 in the counties with the lowest proportions of Black residents.

The rate of PrEP use per 100,000 residents and the PrEP-to-need ratio were a respective 106 and 8.5 in the Northeast; 58 and 3.0 in the South; and 57 and 6.4 in the Midwest.

Patrick Sullivan, PhD, also of Emory University, led the other study, which found that 49% of PrEP users in 2018 lived in the 48 counties being targeted for a ramped-up effort to combat HIV in the new program launched by the federal government, known as the Ending the HIV Epidemic plan. The average rate of PrEP use in these 48 counties was 134 users per 100,000 residents.


Between these 48 counties, there was a wide variation in the rate of PrEP use in 2018. For example, in California, there were 664 PrEP users per 100,000 people in San Francisco County and just 35 PrEP users per 100,000 residents in San Bernardino County, which lies east of Los Angeles.


The number of PrEP-providing clinics per 100,000 residents was a median of 1.7 clinics in the 48 counties, with a low of 0.3 clinics in Cobb County, Georgia, and a high of 6.1 clinics in San Francisco County.


By 2018, half of the 48 counties had already achieved the National HIV/AIDS Strategy goal of increasing PrEP use sixfold between 2015 and 2020. Sullivan and his colleagues project that if current trends persist, 94% of the counties will achieve this target by the end of this year.

“By expanding our visibility into PrEP use at finer geographic levels, like at the county-level, we can increase understanding of service gaps in our local communities, better inform planning and ultimately improve access,” Sullivan said in a press release.

“AIDSVu’s goal with the county-level PrEP data is to empower health departments, policy makers, researchers and community leaders with data to better understand and visualize trends in PrEP use at the local level,” Sullivan continued. “Equipping stakeholders with the tools to monitor progress and address disparities in their communities can inform the development of programs and policies to increase PrEP awareness and access where it is needed most.”

Check out the AIDSVu resources by clicking here.

To read a press release on the new data, click here.

To read the Siegler study, click here.

To read the Sullivan study, click here.