HIV Preexposure Prophylaxis Provision among Adolescents: 2018 to 2021

We identified adolescents aged 13 to 19 years with prescriptions for oral PrEP in the IQVIA Real World Data—Longitudinal Prescriptions database (“IQVIA database”) during 2018 through 2021 using a validated algorithm that distinguishes antiretroviral medications prescribed for PrEP from those prescribed for HIV postexposure prophylaxis or for treatment of HIV and hepatitis B virus infection.^7–10  The IQVIA database includes prescription information, patient demographic information, and the prescriber’s national provider identifier. It includes prescriptions from all types of payers and most clinical settings, including federally qualified health centers, but does not capture prescriptions from closed healthcare systems, such as Kaiser Permanente, or federal systems, such as the Veterans Health Administration. The IQVIA database represents approximately 93% of all prescriptions dispensed by retail pharmacies and 77% of those from mail order outlets in the United States.⁷  Data on race and ethnicity of adolescents were not available for this analysis.

Using previously described methodology,⁹  we linked IQVIA provider data to the Centers for Medicaid and Medicare Services National Plan and Provider Enumeration System and the National Uniform Claim Committee Health Care Provider Taxonomy Code Set to obtain provider characteristics.^11,12  We estimated geographic locations of adolescents by linking their 3-digit zip codes to core-based statistical areas in the US Department of Housing and Urban Development ZIP-USPS crosswalk file.¹³  We identified rural or urban location by linking the zip codes of provider practice location and the Centers for Medicaid and Medicare Services Zip code to Carrier Locality File.¹⁴ 

An adolescent’s sex was assigned in the IQVIA database as male, female, or unknown. An adolescent’s age was determined by the adolescent’s birthyear and the year of the prescription. We categorized the age groups as 13 to 15 years, 16 to 17 years, and 18 to 19 years. Because of small sample sizes, we categorized the age groups as 13 to 17 years and 18 to 19 years for cross-sectional analyses. The adolescents’ geographic locations were described by US region of residence (Northeast, Midwest, South, West) and providers’ locations by their rural or urban designation. Prescription payer type was assigned in the IQVIA database at the prescription level and reassigned at the patient level hierarchically in order of public insurance, private insurance, pharmaceutical company medication assistance program, other assistance program (including federal and state assistance programs, vouchers, discount cards, and other programs), cash, or unknown.¹⁰ 

Provider type was described as physician, nurse practitioner (NP) or physician assistant (PA), or other. Among physicians, provider type was described by specialty.⁹  The physician specialty was assigned hierarchically, with pediatrics assigned the highest tier. Pediatricians were categorized as general pediatricians or pediatric subspecialists, including adolescent medicine, infectious diseases, and other. Other physician categories included general practice, family medicine, and preventive medicine (combined), internal medicine (with subcategories of general internal medicine and infectious diseases), obstetrics and gynecology, and emergency medicine.

We estimated the number of adolescents who were prescribed PrEP each year during 2018 through 2021 and assessed trends by calculating the overall percentage change and the estimated annual percentage change (EAPC) with 95% confidence intervals (CI). We stratified by the adolescents’ sex, age group, and geographic region of residence. Adolescents with PrEP prescriptions in multiple years were counted for each year.

We described the characteristics of adolescents in 2021, the most recent year of data available at the time of analysis, by sex and age group. We described the providers who prescribed PrEP to adolescents in 2021, with stratification by the adolescents’ sex and age group. If a provider prescribed PrEP to adolescents in more than 1 sex or age group, the provider was counted for each category. We performed χ² tests to assess the association between categorical characteristics of the adolescents by sex and age group and between the physician specialty categories by adolescent age group. All analyses were performed using SAS version 9.4 (SAS Institute, Carey, NC).

The number of adolescents we identified who were prescribed PrEP increased 76.2% from 2018 to 2021, with an EAPC of 18.0% (95% CI: 16.6–19.5). In 2018, 3657 adolescents were prescribed PrEP, which increased to 5023 in 2019, decreased to 4898 in 2020, and increased again to 6444 in 2021. These trends are displayed by adolescent sex, age group, and geographic region of residence in Fig 1. The number of male adolescents prescribed PrEP increased from 3071 in 2018 to 5325 in 2021 (EAPC 17.6% [95% CI: 16.0–19.2]). The number of female adolescents increased from 580 in 2018 to 1116 in 2021 (EAPC 20.4% [95% CI: 16.8–24.1]). The number of adolescents aged 13 to 15 years increased from 115 in 2018 to 169 in 2021 (EAPC 9.8% [95% CI: 2.2–18.0]). The number of adolescents aged 16 to 17 years increased from 457 in 2018 to 615 in 2021 (EAPC 8.4% [95% CI: 4.4–12.4]). The number of adolescents aged 18 to 19 years increased from 3085 in 2018 to 5660 in 2021 (EAPC 19.7% [95% CI: 18.1–21.0]). The number of adolescents also increased in each geographic region, with the largest increase among those residing in the South (EAPC 33.3% [95% CI: 30.5–36.2]).

Among 6444 adolescents prescribed PrEP in 2021 (Table 1), most were male (82.6%) and aged 18 to 19 years (87.8%). By region, 40.9% of adolescents with PrEP prescriptions resided in the South, followed by 20.8% in the West, 20.8% in the Northeast, and 16.9% in the Midwest. Most adolescents prescribed PrEP received services in urban areas (94.8%). When stratified by age group and sex, various patterns were observed. Among the 784 adolescents aged 13 to 17 years, 67.3% were male and 32.7% were female. Whereas among the 5660 adolescents aged 18 to 19 years, a higher proportion were male (84.8%, P < .001). Most female adolescents lived in the South (55.2%), with a more dispersed regional distribution among male adolescents (P < .001).

Among all adolescents with PrEP prescriptions in 2021, the most common third-party payer was private insurance (34.6%), followed closely by public insurance (33.3%). Among adolescents aged 13 to 17 years, half (50.9%) had public insurance coverage for the PrEP prescription, compared with less than one-third (30.9%) of adolescents aged 18 to 19 years (P < .001). Among female adolescents, 45.0% had public insurance and 18.9% had private insurance coverage for the PrEP prescription. A different distribution was observed among male adolescents, with 30.9% public insurance coverage and 37.9% private insurance coverage (P < .001).

We identified 4576 individual providers who prescribed PrEP for adolescents in 2021 (Table 2). Of these, 53.7% were physicians and 45.4% were NP or PAs. Among the 2455 physician PrEP providers, 727 (29.6%) were pediatricians, and most pediatricians (71.5%) were general pediatricians. The largest proportion of physician PrEP providers were the combined group of general practice, family medicine, and preventive medicine (41.0%). When stratified by age group, most PrEP providers for adolescents aged 13 to 17 years were physicians (58.2%), and the most common physician specialty was pediatrics (47.6%). The distribution of physician specialty categories was different among providers for adolescents aged 13 to 17 years compared with those aged 18 to 19 years (P < .001). Among the 217 pediatricians who prescribed PrEP to adolescents aged 13 to 17 years in 2021, 67.7% were general pediatricians, 21.7% were adolescent medicine specialists, and 9.2% were pediatric infectious disease specialists. Among the 2105 physicians who prescribed PrEP to adolescents aged 18 to 19 years, 43.3% were general practice, family medicine, or preventive medicine physicians, 26.9% were pediatricians, and 24% were internal medicine physicians. When stratified by sex of the adolescent, similar proportions of providers were pediatricians, with 29.8% for male and 31.7% for female adolescents.

The number of adolescents who were prescribed PrEP increased 76% from 2018 to 2021, with 6444 adolescents prescribed PrEP in 2021. This increase was observed despite health care disruptions caused by the coronavirus disease 2019 (COVID-19) pandemic in 2020. Adolescents of all sex and age groups and in all regions were prescribed PrEP, with a variety of payer and provider types. Adolescents continue to acquire HIV in the United States, and certain populations are disproportionately affected.²  During 2019 through 2021, it is estimated that only 15% to 20% of adolescents and young adults with PrEP indications were prescribed PrEP, with persistent disparities in PrEP coverage by race and ethnicity group, likely because of a variety of factors, including structural barriers and systemic racism.^4,15 

The Centers for Disease Control and Prevention (CDC) recommends that all sexually active adults and adolescents be informed about PrEP and that PrEP should be offered to all who have indications or request it.¹  Similarly, the American Academy of Pediatrics recommends that all youth at risk for HIV acquisition be offered PrEP as part of a comprehensive prevention strategy.³  Indications for PrEP include being sexually active and having any of the following: a recent bacterial sexually transmitted infection, inconsistent or no condom use, a sexual partner who has HIV, a high number of sexual partners, exchange sex, or having sex in an area or sexual network with a high prevalence of HIV.^1,3  Per CDC surveillance data among US adolescents aged 15 to 19 years in 2021, there were 2122 reported cases of primary and secondary syphilis, 101 918 reported cases of gonorrhea, and 375 884 reported cases of Chlamydia, with increasing numbers of syphilis and gonorrhea cases during 2018 through 2021.¹⁶  An sexually transmitted infection diagnosis is an objective measure of condomless sex and an indication to test for HIV and to discuss and, if desired and eligible, to prescribe PrEP. The 2021 US High School Youth Risk Behavior Survey found that 30% of high school students reported having sex and 48% of those who were sexually active reported not using a condom during last sexual intercourse, but only 6% had ever been tested for HIV.¹⁷  Although the increases we observed in PrEP provision are encouraging, pediatric healthcare providers are missing opportunities to prevent HIV among adolescents.

We identified important trends in adolescent PrEP provision. Since the expansion of PrEP approval for all persons weighing at least 35 kg in 2018, we observed increases among both male and female adolescents and among all adolescent age groups. Younger adolescents (aged 13–17 years) had smaller increases compared with older adolescents (aged 18–19 years), which likely reflects slower uptake of this newly available intervention among pediatric providers and younger adolescents. National trends in PrEP coverage demonstrate similar patterns by age, with lower coverage and smaller increases among the adolescent and young adult age group compared with older adults.⁴  In 1 analysis of data collected during 2018 through 2020 among PrEP-eligible US adolescent gay, bisexual, and other men who have sex with men, only 3% had been prescribed PrEP.¹⁸  Additional recent studies of US adolescents in race and ethnicity and sexual orientation and gender identity groups that are disproportionately affected by HIV demonstrate low PrEP awareness and PrEP uptake.^19–21  Potential barriers to PrEP use include multilevel social and structural factors of stigma, fear of disclosure, cost and insurance concerns, low perceived risk of HIV, and low PrEP awareness among adolescents, their guardians, and their providers.^15,19,20  To prevent HIV infections among adolescents and young adults, PrEP awareness, provision, and use must improve.

We observed a decrease in PrEP prescriptions for adolescents in 2020, likely because of the COVID-19 pandemic, followed by increases in 2021. Another analysis using IQVIA data during 2019 through 2021 among persons aged 15 years and older demonstrated similar decreases in PrEP prescriptions, along with decreases in HIV testing, early in the COVID-19 pandemic with subsequent rebounds.²²  They observed the largest decrease in PrEP prescriptions among the adolescent and young adult age group.²²  Disruptions in HIV prevention service provision during the COVID-19 pandemic may have affected younger persons more than adults, and pediatric healthcare providers can play critical role in providing PrEP for adolescents and closing gaps in access and uptake.

The characteristics of adolescents with PrEP prescriptions appear to align with HIV epidemiology among adolescents and adults in the United States. The majority (83%) of adolescents with PrEP prescriptions in 2021 were male and the largest region of residence (41%) was the South. CDC’s HIV surveillance data from 2021 show that 84% of adolescents and young adults with new diagnoses were male and 56% lived in the South.²  Although the number of adolescents with PrEP prescriptions in the South increased substantially during 2018 through 2021, PrEP provision does not appear to meet the need, an observation that is supported by data on the PrEP-to-Need Ratio⁵  and an analysis of all PrEP providers.⁹  Additionally, a large proportion of adolescents had PrEP prescription coverage through public insurance, with higher proportions among younger adolescents and female adolescents. HIV diagnoses, at a community level, are correlated with measures of social vulnerability, of which poverty is a major factor.²³  Areas for further research include assessing the race and ethnicity and sexual behaviors of adolescent PrEP users, as 53% of adolescents and young adults with new HIV diagnoses in 2021 were Black/African American and 82% of male adolescents and young adults had male-to-male sexual contact.² 

Any licensed healthcare provider can prescribe PrEP, and CDC’s PrEP guidelines provide clear recommendations for assessing indications and clinical eligibility for PrEP and for PrEP provision.¹  We observed that a large proportion of PrEP providers for adolescents were NPs or PAs. We focused on describing physician prescribers, and further investigation is warranted to understand the important role of NPs and PAs in PrEP provision. Among physicians, a wide variety of primary care providers, including pediatricians, prescribed PrEP to adolescents, and a proportion of physician prescribers had training in infectious diseases, adolescent medicine, or other specialties. PrEP should be part of routine preventive and primary care and can be an important part of comprehensive sexual, reproductive, and overall healthcare.^1,6  For adolescents who may not regularly access primary care, emergency departments and other clinical settings may be important venues for HIV testing and PrEP education, provision, or referral.

Recent studies have identified low familiarity with PrEP clinical guidelines as a major barrier to PrEP provision among health care providers of adolescents.^24,25  One facilitator for PrEP provision is the use of clinical decision support tools, which can effectively increase knowledge and improve recommended PrEP provision among pediatric healthcare providers.²⁶  Providers can find PrEP providers in their area using the PrEP Locator (https://preplocator.org) and can add themselves to this national directory through the Web site. Pediatric healthcare providers should be prepared to discuss PrEP with all adolescents and to prescribe PrEP to adolescents who may benefit.

This analysis is subject to a few limitations. We were unable to assess the race, ethnicity, gender identity, and sexual behaviors of adolescents prescribed PrEP using these data. These characteristics are important to fully understand PrEP indications and use, and other data sources could be used for such analyses in the future. Additionally, the IQVIA database does not include all US prescriptions. Another limitation is the possibility of misclassifications. If some prescriptions for antiretrovirals identified as PrEP by our algorithm were prescribed for other reasons, such as for postexposure prophylaxis, we may have overestimated PrEP prescriptions. Despite these limitations, this analysis is an important contribution as it provides the first national estimates and description of PrEP provision for adolescents. Areas for future research include assessments of PrEP adherence and persistence among adolescents, which are important attributes of PrEP use that we were unable to assess with these data.

Increases in the number of adolescents prescribed PrEP are encouraging, but also highlight opportunities for improvement. Our findings can provide a baseline for monitoring future trends toward wider and more equitable PrEP provision. The availability of PrEP provides an important opportunity for pediatric healthcare providers to take a more active role in HIV prevention. Pediatric healthcare providers who care for sexually active adolescents, especially in communities disproportionately affected by HIV, should be familiar with PrEP and prescribe it for those who may benefit according to CDC and American Academy of Pediatrics recommendations.

CDC

Centers for Disease Control and Prevention

NP

nurse practitioner

PA

physician assistant

PrEP

HIV preexposure prophylaxis