Medicaid expansion boosts PrEP access for people at risk of HIV diagnosis

Medicaid expansion under the Affordable Care Act (ACA) significantly increased the number of people at risk of HIV diagnosis who were prescribed preexposure prophylaxis (PrEP), a preventative medication taken in pill or injectable form, according to Rutgers Health–led research.

The study, published in Health Affairs, analyzed PrEP prescription data from all 50 states and Washington, D.C., between 2012 and 2023.

Researchers found rates of PrEP prescribing increased overall and significantly increased relative to the number of new HIV diagnoses across all demographic groups, potentially because of overall increases in PrEP access and decreases in HIV diagnoses. Gains in access to PrEP, though, were greater for white populations compared to Black, Hispanic and Latino populations.

"Medicaid expansion is a powerful tool for improving HIV prevention," said Elizabeth Stone, lead author of the study and a core member of the Rutgers Center for Health Services Research at the Institute for Health, Health Care Policy and Aging Research. "But the disparities we observed underscore the need to intentionally address barriers that may be limiting access to PrEP for Black and Hispanic communities specifically."

According to the Centers for Disease Control and Prevention, 35,000 to 40,000 new HIV infections are reported annually in the United States and it is estimated that 36% of people who could benefit from PrEP receive the prescription. Common PrEP medication brands include Truvada and Descovy.

When broken down by race, however, disparities are evident. Ninety-four percent of white Americans who could benefit from PrEP received a prescription in 2022, while 13% of Black Americans and 24% of Hispanic and Latino Americans received prescriptions.

Medicaid, which provides health insurance for disabled and low-income populations, is jointly funded by the federal government and states. The ACA expansion gave states the option to expand coverage to adults with incomes up to 138% of the federal poverty line with increased federal funding for this population. As of November, 40 states and the District of Columbia have expanded their Medicaid coverage through the ACA.

Rutgers researchers said that progress made in HIV prevention through Medicaid expansion is at risk of being lost because of recent policy changes. The One Big Beautiful Bill Act, signed into law in July, eliminates the increased federal funding for Medicaid expansion populations and introduces additional barriers, including work requirements and more frequent eligibility determinations for enrollees. The Congressional Budget Office estimates that over the next 10 years, 7.5 million people will lose Medicaid coverage because of these changes.

In their study, researchers found the strongest increases in the ratio of PrEP prescriptions to new HIV diagnoses occurred among men, individuals ages 25 to 34, and white populations. In contrast, Black, Hispanic and Latino populations, who bear a disproportionate burden of new HIV diagnoses, experienced smaller gains.

"These disparities highlight the limitations of relying solely on state-by-state insurance expansion to close gaps in HIV prevention," said Stone, an instructor in the Department of Psychiatry at Robert Wood Johnson Medical School. "We need policy interventions that address the social and systemic factors driving inequities in PrEP access."

Coauthors of the study include Nicholas Seewald of the University of Pennsylvania and Joseph Rosen of Rhode Island Hospital.