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. 2025 Oct;12(5):3233-3239.
doi: 10.1007/s40615-024-02127-5. Epub 2024 Aug 13.

Structural Racism and HIV Pre-exposure Prophylaxis Use in the Nationwide US: A County-Level Analysis

Fanghui Shi  1   2 , Tianyue Mi  3   4 , Xiaoming Li  3   4 , Huan Ning  5 , Zhenlong Li  5 , Xueying Yang  3   4
Affiliations

Structural Racism and HIV Pre-exposure Prophylaxis Use in the Nationwide US: A County-Level Analysis

Fanghui Shi et al. J Racial Ethn Health Disparities. 2025 Oct.

Abstract

Background: Structural racism contributes to geographical inequalities in pre-exposure prophylaxis (PrEP) coverage in the United States (US). This study aims to investigate county-level variability in PrEP utilization across diverse dimensions of structural racism.

Methods: The 2013-2021 nationwide county-level PrEP rate and PrEP-to-need ratio (PNR) data were retrieved from AIDSVu. PrEP rate was defined as the number of PrEP users per 100,000 population, and PNR was defined as the ratio of PrEP users to new HIV diagnoses per calendar year. Linear mixed effect regression was employed to identify associations of county-level structural racism (e.g., structural racism in housing and socioeconomic status) with PrEP rate and PNR on a nationwide scale of the US.

Results: From 2013 to 2021, the mean PrEP rate and PNR increased from 3.62 to 71.10 and from 0.39 to 10.20, respectively. Counties with more structural racism in housing were more likely to have low PrEP rates (adjusted β = - 5.80, 95% CI [- 8.84, - 2.75]). Higher PNR was found in counties with lower structural racism in socioeconomic status (adjusted β = - 2.64, 95% CI [- 3.68, - 1.61]). Regionally, compared to the Midwest region, counties in the West region were more likely to have higher PrEP rate (adjusted β = 30.99, 95% CI [22.19, 39.80]), and counties in the South had lower PNR (adjusted β = - 1.87, 95% CI [- 2.57, - 1.17]).

Conclusions: County-level structural racism plays a crucial role in understanding the challenges of scaling up PrEP coverage. The findings underscore the importance of tailored strategies across different regions and provide valuable insights for future interventions to optimize PrEP implementation.

Keywords: County level; HIV; Pre-exposure prophylaxis; Structural racism.

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Conflict of interest statement

Declarations. Ethics Approval: This study uses publicly available aggregated data from the AIDSVu, an interactive mapping tool that provides data on HIV prevalence, incidence, and other related health indicators across various geographic levels. The AIDSVu dataset is openly accessible and contains de-identified information, ensuring the privacy and confidentiality of individuals. According to the guidelines of University of South Carolina and federal regulations, research utilizing such publicly available de-identified data does not require approval by an Institutional Review Board (IRB). Therefore, no IRB approval was necessary for this study. Consent to Participate: Not applicable. Consent to Publish: Not applicable. Competing Interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
LOESS smooth curve of PrEP rate and PrEP-to-need ratio by four regions in the United States from 2013 to 2021
See this image and copyright information in PMC

References

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    1. Doherty R, et al. Association of race and other social determinants of health with HIV pre-exposure prophylaxis use: a county-level analysis using the prep-to-need ratio. AIDS Educ Prev. 2022;34(3):183–94. - DOI - PMC - PubMed
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    1. AIDSVu. AIDSVu releases new data highlighting ongoing inequities in PrEP use among Black and Hispanic people and across regions of the country. 2023. [cited 2024 Jan 16]. Available from: https://aidsvu.org/news-updates/news-updates-aidsvu-releases-new-data-hi....
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