Researchers Find Link Between State-Level Policies & PrEP Use

In a report published in the September 2020 issue of Health Affairs, researchers from the University of Pennsylvania School of Nursing, using data from 2018, found that states with laws that criminalize HIV had lower PrEP-to-need ratio, while states with more nondiscrimination laws for sexual and gender minorities had higher PrEP-to-need ratio.

Studying data from all fifty states, Puerto Rico, and Washington DC, they found that although PrEP is “the most efficacious biomedical method of HIV prevention for people at high risk for infection,” and is “particularly relevant for groups that bear a disproportionate burden of HIV, including sexual and gender minorities as well as racial/ethnic minorities,” the people who could most from using PrEP have been slow to utilize this HIV prevention method.

The researchers tied this lack of PrEP use among sexual, gender, and racial/ethnic minorities to the stigmatizing effect of state laws that criminalize the transmission of HIV to sexual partners. These laws, they found, exacerbate HIV stigma and inhibit motivation to know one’s status and to seek HIV prevention services, especially among younger adults. They write, “Previous research has found that HIV criminalization laws can negatively influence HIV testing, undermine trust between patients and medical providers, and reduce the proportion of people living with HIV who receive a diagnosis. HIV criminalization may promote stigma against people living with HIV and discourage those seeking sexual health services, but it may also reflect a more pervasive cultural climate of stigma.”

Researchers also found that states in the South showed much lower PrEP-to-need ratio than states in the Northeast or the West. While noting that six of the seven states identified by the federal Ending the HIV Epidemic program as having a disproportionate incidence of HIV in rural areas, particularly among African American and Latinx communities, researchers also noted that states with large urban areas (California, Texas, Florida) also evidenced low PrEP-to-need ratios. They found that these differences stemmed from racial demographics. Patients in those states with low PrEP use report greater experience of stigma and discrimination in their communities and a lack of cultural competence among healthcare providers.

Surprisingly, the researchers found no association between Medicaid expansion, Ryan White funding, percentage uninsured, median household income, percentage with high school education, or state population and PrEP uptake. They conclude that “[s]tate-level policy can shape and is shaped by the local political and cultural climate, and the specific policies enacted by state legislatures have the potential to affect HIV prevention efforts. The Ending the HIV Epidemic initiative identifies HIV prevention as one of the plan’s four key pillars and highlights PrEP as a primary HIV prevention strategy. Laws that protect sexual and gender minorities from discrimination can strengthen this pillar, whereas HIV criminalization laws may weaken it. Progress toward ending the HIV epidemic will require revisiting structural policies and strengthening those that enable HIV prevention while removing or reforming the policies that impede it. Legislators should consider how the laws they pass might promote or subvert stigma and fear surrounding HIV. Actions by state governments have the power to influence, directly or indirectly, the course of the HIV epidemic in their states.”

—Reporting by Hank Trout


Hank Trout, Senior Editor, edited Drummer, Malebox, and Folsom magazines in the early 1980s. A long-term survivor of HIV/AIDS (diagnosed in 1989), he is a forty-year resident of San Francisco, where he lives with his husband Rick Greathouse. Follow him on Twitter @HankTroutWriter.