HIV Pre-Exposure Prophylaxis Use and Equity in an Urban,Multi-Site Federally Qualified Health Center

Abstract

Background:

Access Community Health Network (ACCESS) is a multi-site network of Federally Qualified Health Centers (FQHCs) located in Chicago that predominately serves Black and Hispanic/Latino patients who experience disproportionate HIV burden. FQHCs must endeavor to provide equitable access to pre-exposure prophylaxis (PrEP) for at-risk patients, but standardized epidemiological methods for assessing PrEP provision in health care settings are lacking.

Methods:

We compared the demographic characteristics of patients who received at least one PrEP prescription to those of patients who were diagnosed with HIV from January 1, 2023, to December 31, 2024, excluding patients aged <14 years. We divided the number of PrEP users by the number of HIV diagnoses to generate PrEP-to-need Ratios (PnRs), which were used to examine potential disparities by age, gender, race/ethnicity, sexual orientation, and insurance status. We compared patterns of PrEP use at ACCESS to local epidemiological trends using data from AIDSVu.

Results:

During the study period, the overall PnR among patients was 9.5. In contrast to local PrEP utilization trends, the PnR in patients was negatively associated with age and higher in females (11.3) than males (8.2). We observed higher PnRs among privately insured patients (14.2) than publicly (9.9) and uninsured patients (6.4).

Conclusion:

To our knowledge, this is one of the first studies to apply the PnR to assess PrEP use and equity in a health care organization. By adapting population-based surveillance strategies to our context, we produced high-quality epidemiological information to drive health equity initiatives.

Keywords

PrEP pre-exposure prophylaxis HIV Federally Qualified Health Center health disparities health equity

Background

HIV pre-exposure prophylaxis (PrEP) reduces the risk of HIV acquisition from sex by approximately 99% and from injection drug use by more than 75% when taken as prescribed.^1,2 Approximately one-quarter of PrEP prescriptions in the United States are accessed through community health centers (CHCs), which deliver primary care and prevention services to more than 30 million patients from traditionally underserved populations with elevated HIV risk.³

Despite PrEP’s effectiveness, only slightly more than one-third of individuals in the United States who have PrEP indications use it.⁴ The Ending the HIV Epidemic (EHE) initiative aims to increase the number of PrEP users to 1.2 million by 2030 and improve PrEP equity by providing resources to United States jurisdictions with high HIV incidence.⁵ CHCs are the primary setting for PrEP scale-up; however, provision in CHCs is at least 25% lower than levels needed to attain the EHE target.³ There are widening disparities in PrEP access among Black persons, who represent 38% of new diagnoses and only 14% of PrEP users, and women, hindering progress toward EHE goals.^4,6,7

CHC interventions to improve PrEP uptake must target groups at the highest risk of acquiring HIV.⁸ However, standardized methods for assessing PrEP access among patients are underdeveloped. The PrEP-to-need Ratio (PnR) reflects the number of PrEP users per person diagnosed with HIV; it was originally used to quantify how well the need for PrEP was met in United States geographies^9,10 and has been more recently applied in an urban patient population.¹¹ The PrEP Equity Ratio (PER) is the ratio of two PnRs (e.g., for females vs. males).⁶ While there is no ideal PnR target, comparing PnRs between groups can help identify disparities in PrEP access. These approaches expand on traditional methods for quantifying PrEP coverage that estimate PrEP need based on sexual behavior and substance use data from population-based surveys.¹² Studies of PrEP utilization have been conducted relative to PrEP indications documented in patient sexual histories, including multiple sexual partners and condomless sex.^11,13 However, despite the importance of collecting these data to accurately assess HIV risk and patients’ appropriateness for PrEP,¹⁴ they are often unavailable for epidemiological analysis; primary care providers commonly defer targeted questions about sex due to more urgent health issues and a lack of skill and comfort in having these conversations.^15,16 In contrast, most health care organizations can measure the PnR using routinely collected data.

Access Community Health Network (ACCESS) is the sixth largest network of Federally Qualified Health Centers (FQHCs) in the United States and the largest primary care provider of Medicaid enrollees in Illinois, serving more than 150,000 patients annually, including approximately 830 patients with HIV. Of ACCESS’ 35 health centers, four are in DuPage County and 31 are in Cook County, which includes Chicago, an EHE priority jurisdiction. HIV incidence and prevalence in Chicago are more than twice national rates (27 vs. 3 per 100,000 and 801 vs. 388 per 100,000, respectively). There are also HIV-related disparities in Chicago, particularly among females and racial/ethnic minorities.^17–20 The objectives of this study are to evaluate patterns of PrEP use among ACCESS patients by age, race/ethnicity, gender, sexual orientation, and insurance status, and to examine how they align with local epidemiological trends.

Methods

Study Population

Our study population was comprised of ACCESS patients who used PrEP or were diagnosed with HIV from January 1, 2018, to December 31, 2024. PrEP users were defined as non-HIV-infected patients who received one or more prescriptions for Truvada® (tenofovir disoproxil fumarate/emtricitabine) or Descovy® (tenofovir alafenamide/emtricitabine) from an ACCESS provider using an internal prescription database, excluding patients who had a diagnosis of hepatitis B or received an order for raltegravir potassium (indicative of post-exposure prophylaxis) the same year as a PrEP order. Patients who were diagnosed with HIV were obtained from CAREWare, an online database and reporting system for Ryan White HIV/AIDS Program providers.²¹ The total patient population, which served as the denominator for prevalence calculations, consisted of all patients who had one or more visits at ACCESS during the study period. Patients <14 years old were excluded from analysis.

Variable Definitions

We used data from ACCESS’ electronic health record (EHR) to classify age, sexual orientation, and insurance status. Self-reported sexual orientation was classified as heterosexual/straight, gay or lesbian, or a third category combining bisexual and “something else.” We classified insurance status as uninsured, public (combining Medicaid and Medicare), or private, based on the payor billed on the PrEP prescription or HIV diagnosis date, as appropriate. If a billable visit on that date could not be found in the EHR, the payor billed for the visit nearest to (but no more than 365 days from) the date was analyzed. Patients in the reference population were assigned to an insurance type based on the payor most frequently billed for their visits during the study.

PrEP users’ self-reported gender and race/ethnicity were classified using EHR data. However, we utilized a combination of data from the EHR and CAREWare for patients diagnosed with HIV because CAREWare data were more complete. Regardless of the data source, categories of race/ethnicity included Hispanic/Latino (of any race), non-Hispanic Black (NHB), non-Hispanic White (NHW), and non-Hispanic other races, which included all other non-Hispanic patients whose race was documented. Gender was assigned as female, male, or nonbinary/genderqueer, which included nonbinary, genderqueer, transgender, and “other” genders. PrEP users missing gender identity were assigned according to their sex.

We examined groups jointly stratified by gender and race/ethnicity, including Hispanic/Latina females, Hispanic/Latino males, NHB females, NHB males, NHW females, NHW males, non-Hispanic females of other races, and non-Hispanic males of other races. Intersections of gender and sexual orientation included heterosexual female, heterosexual male, and men who have sex with men (MSM). We identified MSM using a binary variable in CAREWare for patients with HIV. The EHR lacks a similar indicator variable; therefore, PrEP users were classified as MSM if their gender identity was male, transgender male, or other, and their self-reported sexual orientation was gay, bisexual, or something else.

Statistical Analysis

The prevalence of PrEP use was defined as the number of ACCESS patients using PrEP per 10,000 patients with at least one visit during the same period. We calculated the PnR as the number of PrEP users divided by the number of patients diagnosed with HIV.

We plotted PnRs by year from 2018 to 2024 to assess longitudinal trends in PrEP uptake. We evaluated the distributions of patients using PrEP and those diagnosed with HIV, the prevalence of PrEP use, the PnR, and the PER from January 1, 2023, to December 31, 2024, by age, gender, race/ethnicity, sexual orientation, and insurance status. We chose a 2-year period for the cross-sectional analysis to maximize the data available for stratified analysis. Percentages of patients (not counts) are reported from the stratified analysis, in alignment with the Centers for Medicare & Medicaid’s (CMS’) cell suppression policy.²² We considered a potential unmet need for PrEP to exist if the proportion of patients diagnosed with HIV exceeded the proportion of PrEP users in a subpopulation. We generated PERs by age, gender, and insurance status, and between groups jointly stratified by sexual orientation and gender, in reference to the stratum with the highest PnR. For comparisons by race/ethnicity and between gender-stratified racial/ethnic groups, the stratum with the highest PnR among NHB and Hispanic/Latino patients served as the reference, given that NHW patients and non-Hispanic patients of other races represent a minority of patients infected with HIV. Equal PnRs across strata of a given demographic characteristic (i.e., PER = 1.0) indicate equitable access.

ACCESS primarily serves residents of Cook County, who account for 57% of new HIV infections in Illinois.²³ We assessed distributions of residents diagnosed with HIV and those using PrEP and the PnR in Cook County or Illinois (if county-level data were unavailable) in 2022, stratified by age, gender, and race/ethnicity, from AIDSVu.²⁴ The median age in Cook County is 38, and women comprise slightly more than half (51.2%) of the population. The approximate racial/ethnic distribution is 41% NHW, 26% Hispanic/Latino, 22% NHB, and 11% other race/multiracial.²⁵

This study was completed as a quality improvement activity, and the Mount Sinai Hospital Institutional Review Board determined that the investigation was not research as defined in 45 CFR 46.102(l). All analyses were performed in R, version 4.4.2 (https://www.r-project.org/).

Results

Trends in PrEP Use from 2018 to 2024

From 2018 to 2024, the prevalence of PrEP use increased by 46% to 34 per 10,000 patients, and the PnR increased by a factor of 2.7 (Fig. 1). In 2024, there was a 60% increase in the PnR compared to the prior year, from approximately 10 to 16 (Cook County PnR = 21.6),²⁴ which was driven by a decline in HIV diagnoses.

FIG. 1.

Rates of HIV diagnoses and PrEP use and the PrEP-to-need Ratio among ACCESS patients (2018–2024). Rates and PnR values are not displayed to prevent identification of individual patients, in alignment with the Centers for Medicare & Medicaid’s (CMS’) cell suppression policy. ACCESS, Access Community Health Network; PnR, PrEP-to-need Ratio; PrEP, pre-exposure prophylaxis.

Cross-Sectional Analysis

Description of the total patient population

The characteristics of ACCESS patients aged ≥14 years who had at least one visit at ACCESS from January 1, 2023, to December 31, 2024, are displayed in Table 1. The median patient age aligned with the county median. However, the gender and racial/ethnic background of patients differed from county-level demographics. Approximately 62% of ACCESS patients included in the study were Hispanic/Latino, and 6% were NHW (vs. 26% and 41% of county residents, respectively). MSM comprised 1% of patients, and <1% identified as nonbinary/genderqueer.

Table 1.

Distributions of Patients Using PrEP, Patients Diagnosed with HIV, and Patients with at Least One Visit at ACCESS, the PrEP-to-need Ratio, and the PrEP Equity Ratio, by Select Demographic Characteristics (January 1, 2023–December 31, 2024)

	All patients aged ≥14 years	Received PrEP	Diagnosed with HIV	PrEP users per 10,000 patients	PnR	PER
Age
Median age, SD (IQR)	37, 17.1 (23, 51)	29, 10.7 (23, 37)	35, 11.9 (27, 40)	**	**	**
14–24 years	27.9%	32.9%	16.9%	45.7	18.5	ref.
25–34 years	18.4%	35.8%	32.3%	75.3	10.6	0.6
35–44 years	18.0%	18.5%	27.7%	39.9	6.4	0.3
≥45 years	35.6%	12.7%	23.1%	13.9	5.3	0.3
Race/ethnicity
Hispanic/Latino	61.5%	45.0%	41.5%	28.3	9.1	ref.
NHB	26.2%	41.9%	49.2%	61.8	7.2	0.8
NHW	6.2%	9.9%	3.1%	61.7	27.0	3.0
Non-Hispanic other races	6.2%	3.3%	6.2%	20.7	4.5	0.5
Gender
Female	62.9%	43.6%	36.9%	26.9	11.3	ref.
Male	36.8%	54.4%	63.1%	57.3	8.2	0.7
Nonbinary/Genderqueer	0.3%	1.9%	0	240.0	**	**
Sexual orientation by gender
MSM	1.0%	41.2%	36.9%	1522.4	9.8	0.9
Heterosexual female	62.0%	40.0%	33.9%	26.4	10.9	ref.
Heterosexual male	34.1%	10.3%	25.4%	12.4	3.7	0.3
Race/ethnicity by gender
Hispanic/Latina female	38.5%	16.6%	10.8%	16.4	12.7	ref.
Hispanic/Latino male	23.0%	28.4%	30.8%	46.8	7.6	0.6
NHB female	17.9%	27.8%	24.6%	58.9	9.3	0.7
NHB male	8.3%	14.4%	24.6%	66.2	4.8	0.4
NHW female	3.6%	2.4%	0	25.4	**	**
NHW male	2.5%	7.1%	3.1%	106.5	19.0	1.5
Non-Hispanic females of other races	3.7%	0.6%	1.5%	5.8	3.0	0.2
Non-Hispanic males of other races	2.5%	2.8%	4.6%	42.6	5.0	0.4
Insurance status
Uninsured	20.2%	11.8%	18.6%	21.7	6.4	0.4
Public	59.6%	59.6%	61.0%	37.2	9.9	0.7
Private	20.2%	28.6%	20.3%	52.5	14.2	ref.

The proportion of PrEP users who were missing demographic data was <1% for gender, 4.0% for insurance status, 8.4% for MSM status, 11.6% for race/ethnicity, and 12.4% for sexual orientation. Patients diagnosed with HIV were missing data for sexual orientation (9.2%) and insurance status (9.2%).

When data are not available or are suppressed, “**” is displayed.

PnR, PrEP-to-need Ratio; SD, standard deviation; IQR, interquartile range; ref., reference; MSM, men who have sex with men; NHB, non-Hispanic Black; NHW, non-Hispanic White.

PrEP utilization and equity

In 2023 and 2024, the overall PnR was 9.5. The prevalence of PrEP use was highest among patients aged 25–34 (75.3/10,000), similar among patients aged 14–24 (45.7/10,000) and 35–44 (39.9/10,000), and lowest in patients 45 and older (13.9/10,000) (Table 1). The PnR among ACCESS patients also decreased with age. There was evidence of an unmet need for PrEP in the two oldest age groups, which collectively accounted for approximately half of HIV diagnoses and slightly less than one-third of PrEP users (Fig. 2). In contrast, the PnR in Cook County was higher among residents aged 35–44 years (28.3) and those 45 and older (24.8) than residents 25–34 years (20.7) and 14–24 years (11.8), and the need for PrEP was disproportionately low in the youngest age group, which represented 9% of PrEP users and 17% of HIV diagnoses.

FIG. 2.

Distribution of patients using PrEP, distribution of patients diagnosed with HIV, and the PrEP-to-need Ratio at ACCESS and in Cook County, by age group (January 1, 2023–December 31, 2024). The PnR for Cook County in residents aged ≥45 years was derived by calculating the weighted average of the PnR for people aged 45–54 (PnR = 26.2) and people aged ≥55 (PnR = 23.3). PnR, PrEP-to-need Ratio; PrEP, pre-exposure prophylaxis.

The prevalence of PrEP use was twice as high in male patients compared to female patients (57.3/10,000 vs. 26.9/10,000, respectively) and greatest in those identifying as nonbinary/genderqueer (240.0/10,000). However, relative to epidemiological need, PrEP use was approximately 30% lower in male vs. female patients (PnR = 8.2 vs. 11.3, respectively, PER = 0.7), and the distribution of PrEP users in males was substantially lower than the share of HIV diagnoses they represented (54.4% vs. 63.1%, respectively) (Fig. 3). We observed divergent gender-specific trends in Cook County, where the PnR was threefold higher in males than females (PnR = 24.4 vs. 7.7, respectively, PER = 3.2).

FIG. 3.

Distribution of patients using PrEP, distribution of patients diagnosed with HIV, and the PrEP-to-need Ratio at ACCESS and in Cook County, by gender (January 1, 2023–December 31, 2024). A PnR was not publicly reported for Cook County residents who identified as nonbinary/genderqueer. PnR, PrEP-to-need Ratio; PrEP, pre-exposure prophylaxis.

Rates of PrEP use were similar among NHW patients (61.7/10,000) and NHB patients (61.8/10,000) and were lower in Hispanic/Latino patients (28.3/10,000) and non-Hispanic patients of other races (20.7/10,000) (Table 1). The PnR was highest among NHW patients (27.0), followed by Hispanic/Latino (9.1) and NHB (7.2) patients, consistent with patterns observed in Illinois (Fig. 4). However, racial/ethnic differences in PrEP among patients were smaller in magnitude; the PER among NHB vs. Hispanic/Latino persons was 0.8 at ACCESS vs. 0.5 statewide. The distribution of PrEP users was commensurate with the share of HIV diagnoses experienced by Hispanic/Latino patients, while it was disproportionately low in NHB patients (41.9% of PrEP users vs. 49.2% of HIV diagnoses).

FIG. 4.

Distribution of patients using PrEP, distribution of patients diagnosed with HIV, and the PrEP-to-need Ratio at ACCESS and in Illinois, by race/ethnicity (January 1, 2023–December 31, 2024). A PnR was not publicly reported for Illinois residents of non-Hispanic other races. NHB, non-Hispanic Black; NHW, non-Hispanic White; PnR, PrEP-to-need Ratio; PrEP, pre-exposure prophylaxis.

Exploring jointly stratified demographic variables, we found that PrEP use among patients was most prevalent in NHW males (106.5/10,000), NHB males (66.2/10,000), and NHB females (58.9/10,000) (Table 1). The PnR was greater in Hispanic/Latina females (12.7) and NHB females (9.3) than their male counterparts (7.6 and 4.8, respectively). There was evidence of an unmet epidemiological need for PrEP among NHB males and heterosexual males, who accounted for 14.4% and 10.3% of PrEP users (respectively) and each accounted for one-quarter of HIV diagnoses.

There were also insurance-related differences in PrEP provision. The prevalence of PrEP use was greater among patients who were privately insured (52.5/10,000) or publicly insured (37.2/10,000) compared to uninsured patients (21.7/10,000). There were disparities in the PnR among uninsured (6.4, PER = 0.4) and publicly insured patients (9.9, PER = 0.7) relative to those with private insurance (14.2).

Discussion

We found that PrEP use and the PnR increased at ACCESS from 2018 to 2024 and that demographic patterns of PrEP utilization among patients varied from community-level epidemiological trends, especially with respect to gender and age. Understanding inequities in PrEP access in patient populations, and how they may differ from those of the local community, is critically important in FQHC settings, given that CHCs providing care to a disproportionate share of patients who are NHB and Hispanic/Latino are more likely to dispense PrEP than those serving predominantly White, insured patients.³ We documented PrEP inequity among patients who lacked health insurance, which aligns with prior research¹¹ and highlights the importance of connecting patients who lack coverage with drug assistance programs (e.g., PrEP4Illinois) to reduce financial barriers to HIV prevention services.

NHB male patients were underrepresented among PrEP users, while PrEP utilization among NHB female and Hispanic/Latina female patients exceeded the burden of HIV infection experienced by these groups. These findings would not have been apparent had we not analyzed intersections of gender and race/ethnicity. There is greater potential to generate meaningful information by evaluating disparities using methods that involve joint stratification by two or more variables, compared to approaches in which these same variables are assessed independently, and intersectionality-informed methods have the potential to maximize the impact of study findings by more precisely measuring differences between groups.^26–28 Patterns of PrEP use in NHB female and Hispanic/Latina female patients may reflect institutional efforts to engage women in PrEP, for example, by integrating best practice advisory notifications in the EHR that are triggered predominantly by female patients receiving STI testing. Future interventions should address the specific needs of NHB men, who may be less aware of PrEP than their female counterparts.^29,30 There is also a need for further investigation of modifiable factors potentially influencing PrEP uptake in NHB male patients, such as self-perceived risk, PrEP stigma, biases of medical staff, and STI screening routines, all of which have been found to contribute to PrEP uptake.^8,31

Our findings demonstrate benefits and limitations of using the PnR to measure PrEP equity in patient populations. PnRs are generated using data that are readily available to most health care organizations and facilitate rapid identification of potential gaps in access. However, while high PnRs may signify successful HIV prevention efforts resulting in a smaller denominator of incident HIV infections, they may also reflect PrEP uptake in groups with low HIV risk, precluding the establishment of PnR benchmarks.¹¹ The number of health system patients diagnosed with HIV may also fluctuate from 1 year to the next for reasons unrelated to HIV prevention, like changes in overall health care utilization and insurance coverage. Additionally, we found evidence of PrEP inequity, as indicated by unequal PnRs, in groups for which the need for PrEP was met based on the relative distribution of PrEP users and patients diagnosed with HIV. To account for these challenges, investigators may consider assessing rolling averages of the PnR to measure PrEP equity longitudinally. It is also important to interpret PnR trends in combination with other assessment strategies, such as comparing rates of PrEP use and to the extent possible, employing other proxies of PrEP need. We encourage additional health systems to report results of analyses in their own organizations to expand the knowledge base and to further demonstrate the utility of the PnR in health care settings.

Our study has several noteworthy limitations. Firstly, PrEP use was defined as having received at least one prescription for PrEP during the study period, which does not account for adherence to prescribed regimens. If there was poor adherence to PrEP among patients, the PnRs we reported were likely overestimations of PrEP utilization. PrEP adherence is not well understood; estimates of adherence from clinic-based and observational studies range from approximately 70% to 85%, though there is variability in the methods used to measure outcomes and large differences in adherence by race/ethnicity, gender, and age.^1,32,33 Further investigation into PrEP adherence and persistence in diverse populations is needed.

There are additional measurement-related limitations, including a considerable amount of missing data for important stratifying variables that differentially affected PrEP users, including sexual orientation and race/ethnicity. Prior research suggests that unreported race data is disproportionately attributed to NHB and Hispanic/Latino people,³⁴ who are the majority of ACCESS patients; if these patterns exist in our study population, the PnR in NHB and Hispanic/Latino patients is potentially higher than reported in this study. Additionally, we may have introduced bias by using sexual orientation to identify MSM among PrEP users. Approximately 12% of PrEP users were missing sexual orientation data, and there is evidence that some MSM do not identify as gay, homosexual, or bisexual on population surveys.^35,36 As a result, the proportion of PrEP users classified as MSM and the MSM-specific PnR in this study could be underestimated. Lastly, we compared our findings to the local epidemiology of Cook County and Illinois due to data availability, whereas the city of Chicago would have been a more appropriate reference group given its demographic profile.

Conclusion

Despite these limitations, our study has several strengths. It expands on prior population-based analyses of PrEP equity by measuring PrEP use and equity at cross-sections of gender, race/ethnicity, and sexual orientation, rather than focusing on a single social position. Also, to our knowledge, this study is one of the first to apply the PnR to assess PrEP use and equity in a health care organization. By adapting population-based surveillance strategies to our context in a flexible way, we produced high-quality epidemiological information to drive public health action within ACCESS without collecting additional risk data from patients. We hope that our approach will serve as a model for other health care organizations interested in conducting similar analyses.

Authors’ Contributions

J.V.: Conceptualization (lead); data curation (lead); formal analysis (lead); methodology (lead); writing—original draft (lead); writing—review and editing (lead). K.Y.: Conceptualization (supporting); data curation (supporting); methodology (supporting); writing—review and editing (supporting). M.S.: Conceptualization (supporting); methodology (supporting); writing—review and editing (supporting). L.R.: Conceptualization (supporting); methodology (supporting); funding acquisition (equal); supervision (lead); writing—review and editing (supporting). D.L.: Conceptualization (supporting); funding acquisition (equal); supervision (supporting); writing—review and editing (supporting).

Footnotes

Acknowledgments

The authors want to thank the patients and staff of Access Community Health Network who made this study possible.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This study was made possible in part by a larger grant to Access Community Health Network from the City of Chicago as part of the Health Care Access: Population Centered Health Homes program in May 2025 (Award Number 116619).

Abbreviations

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