Abstract
To the Editor:
Pre-exposure prophylaxis (PrEP) is a highly effective HIV prevention intervention and remains central to national and state efforts to reduce new HIV infections.1,2 Despite increases in PrEP use since Federal Drug Administraion approval (Truvada, July 2012, and Descovy, October 2019), uptake remains uneven, with persistent racial, ethnic, geographic, and other disparities among populations most affected by HIV.3,4 These inequities are especially relevant in Wisconsin, where recent HIV surveillance data show continued racial and ethnic disparities in new diagnoses and increasing concern about HIV among people who inject drugs, young Black/African American and Hispanic men who have sex with men, and transgender women of color.5,6 Although Wisconsin routinely reports HIV treatment and care indicators, state-level PrEP use and prescribing patterns are less consistently characterized. To inform HIV prevention efforts aligned with Wisconsin’s Integrated HIV Prevention and Treatment Plan 5 and the Ending the HIV Epidemic initiative, 2 we examined statewide PrEP use, PrEP-to-need ratios (PnRs), and prescribing practices to characterize gaps in HIV prevention delivery.
We used AIDSVu 7 and Wisconsin Health Information Organization (WHIO) 8 all-payer claims data to examine PrEP use and prescribing patterns in Wisconsin. AIDSVu data from 2012 to 2022 were used to assess annual statewide PrEP use and PnRs, overall and by sex, age, and race/ethnicity. PnR was defined as the number of PrEP users divided by the number of new HIV diagnoses in a given year. WHIO prescription claims from January 2017 through June 2023 were used to identify Truvada (emtricitabine and tenofovir disoproxil fumarate) and Descovy (emtricitabine and tenofovir alafenamide) claims prescribed by Wisconsin providers and to examine patient sex, age, county of residence, rural/urban classification, medication type, and provider specialty. We summarized characteristics descriptively, used linear regression to assess trends in PrEP use and PnRs over time, and used logistic regression to examine associations between patient/provider characteristics and medication type.
In AIDSVu data, PrEP use and PnRs increased substantially in Wisconsin from 2012 to 2022. Statewide PrEP use increased from 74 users to 3342 users from 2012 to 2022, and the overall PnR increased from 0.34 to 13.21. In linear regression models (Table 1), both PrEP use and PnR increased significantly over time. However, racial and ethnic gaps persisted. Annual increases in PrEP use were much larger among White individuals than among Black and Hispanic individuals, and 2022 PnRs remained substantially lower among Black and Hispanic individuals than White individuals, indicating continued unmet PrEP need despite overall statewide improvement. Therefore, Wisconsin’s overall PrEP expansion appears to be masking persistent racial and ethnic inequities in PrEP access relative to HIV need.
Linear Regression Results for Annual Trends in PrEP Use and PrEP-to-Need Ratios by Demographic Characteristics, Wisconsin, 2012 to 2022
*significant at p < 0.05.
PnR, PrEP-to-need ratio; PrEP, pre-exposure prophylaxis.
To further characterize prescribing patterns, WHIO claims data identified 58,994 PrEP prescription claims from January 2017 through June 2023, including 41,698 claims prescribed by Wisconsin providers. Among Wisconsin-provider claims, nearly two-thirds were for Truvada (26,610; 63.8%), and 36.2% were for Descovy (15,088). Most claims were among male patients (80.7%) and urban residents (80.7%), with claims concentrated in Southern (36.9%) and Southeastern Wisconsin (36.4%). By provider specialty, infectious disease providers accounted for the largest share of claims (33.7%), followed by nurse practitioners (23.5%) and family medicine providers (16.3%). Across the study period, total PrEP claims declined after 2019; this decrease was driven primarily by declining Truvada claims beginning in 2020 and accelerating in 2021, whereas Descovy claims remained comparatively stable from 2019 to 2022 before decreasing slightly.
Logistic regression models (Table 2) showed that medication type differed by patient, geographic, and provider characteristics. Descovy was more likely among female patients, adults aged 25 to 44 years, patients in Southern and Western Wisconsin, and claims prescribed by family medicine, internal medicine, physician assistant, and other provider categories. In contrast, Truvada was more likely prescribed among older adults, rural residents, patients in Southeastern and Northeastern Wisconsin, and claims prescribed by infectious disease providers. Over time, claims from infectious disease providers decreased while claims from primary care providers increased, suggesting a gradual shift in PrEP delivery from specialty care toward primary care settings.
Logistic Regressions Results for Medication Type Among Wisconsin Provider Claims in WHIO, January 2017 to June 2023
*significant at p < 0.05.
PnR, PrEP-to-need ratio; PrEP, pre-exposure prophylaxis; WHIO, Wisconsin Health Information Organization.
This work suggests that Wisconsin has made measurable progress in expanding PrEP use, but that progress has not eliminated inequities in PrEP access relative to HIV need. The persistent racial and ethnic gaps in PnR are particularly important, as they suggest that statewide gains may obscure unmet need among Black and Hispanic individuals, who remain disproportionately affected by HIV. 6 This pattern aligns with national evidence showing that PrEP uptake has increased overall while remaining inequitably distributed across racial and ethnic groups, 9 underscoring the need for equity-focused implementation strategies rather than broad PrEP expansion alone. These strategies may include strengthening PrEP referral pathways and supporting culturally aligned, community-initiated approaches that build trust, reduce stigma, and address locally specific barriers to PrEP access. The decline in WHIO PrEP claims after 2019 also suggests that PrEP delivery may be vulnerable to disruptions in health care access, as seen nationally during the COVID-19 pandemic. 10 The relative stability of Descovy claims during the period when Truvada claims declined may reflect changing medication prescribing patterns, including medication switching, 11 though these patterns should be interpreted cautiously given differences in medication approval timelines and clinical indications. Recent national claims-based evidence also suggests that Truvada and Descovy use differs by HIV risk factors, prior sexually transmitted infections, provider type, and US region, further supporting the importance of examining medication-specific PrEP prescribing patterns at the state level. 12 Finally, the observed shift from infectious disease to primary care prescribing has important implications for Wisconsin and other states seeking to expand PrEP access. Given national attention to expanding PrEP delivery, primary care may be increasingly central to PrEP delivery, creating opportunities to normalize HIV prevention in routine care and reach patients who may not access specialty sexual health or HIV services. However, expanding PrEP through primary care also requires implementation strategies that strengthen provider knowledge, support PrEP-related clinical decision-making, and streamline clinic workflows to promote efficient and effective PrEP delivery that is responsive to patient needs.
These findings should be interpreted in light of several limitations. WHIO claims capture prescriptions, not PrEP adherence, persistence, or unmet need among individuals who were not prescribed PrEP. WHIO data also lacked race/ethnicity, HIV risk or behavioral indicators, diagnostic codes, and inclusive gender identity measures, which limited analyses of inequities among key populations and certainty that all included claims represented PrEP for HIV prevention. In addition, WHIO does not include all Wisconsin residents, some claims had missing demographic variables, and AIDSVu and WHIO differ in scope and measurement.
Despite these limitations, combining public PrEP surveillance data with all-payer claims data provides a useful approach for monitoring PrEP implementation at the state level. State-level monitoring can help identify where broad PrEP expansion is insufficient and where implementation resources should be directed to populations and regions with persistent unmet need. Wisconsin’s experience highlights the importance of tracking not only whether PrEP use is increasing, but also who is being reached, where prescribing is occurring, and which providers are delivering PrEP. These data can inform targeted, equity-focused implementation strategies to strengthen PrEP access in Wisconsin and in other jurisdictions pursuing Ending the HIV Epidemic goals.