A policy meant for all, and the gap between availability and access

There is a particular kind of progress that, when examined closely, reveals itself to be unevenly distributed. A policy is written with the intention of helping everyone equally, but the path from intention to outcome is shaped by forces that no single law can fully control—access to transportation, trust in medical institutions, the quiet weight of historical inequity. Two new studies examining HIV prevention policies in the United States suggest that supportive state environments do increase access to prevention tools, but the benefits do not always reach the communities that need them most.

The first study, published in Health Affairs and led by researchers at Rutgers Health, analyzed PrEP prescription data from all 50 states and Washington, D.C., between 2012 and 2023. It found that Medicaid expansion under the Affordable Care Act significantly increased the ratio of PrEP prescriptions to new HIV diagnoses across all demographic groups. The effect grew over time, from a small increase in the first year of expansion to a substantial one by the tenth year .

But when the researchers examined the results by race and ethnicity, a different picture emerged. The greatest increases in the PrEP-to-need ratio were observed among White populations, even though White Americans account for fewer than one-quarter of new HIV diagnoses. In 2022, 94 percent of White Americans who could benefit from PrEP received a prescription, compared with 13 percent of Black Americans and 24 percent of Hispanic and Latino Americans . The study's lead author, Elizabeth Stone, said the disparities underscored the need to address barriers that may be limiting access for Black and Hispanic communities specifically .

A second study, published in the journal AIDS and Behavior, examined state HIV prevention policy environments more broadly. Researchers constructed indices of access-focused, attitude-focused, and punitive policies as of January 2024, then linked them to a national survey of men who have sex with men and transgender women. They found that supportive access-focused and attitude-focused policies were associated with higher PrEP use and recent HIV testing among White participants. For Black and Latinx participants, those associations were not statistically significant .

The researchers suggested that differences in access and norms may explain the gap. A policy that makes PrEP theoretically available does not automatically make it reachable. Transportation, clinic hours, insurance navigation, language, and trust in a healthcare system that has historically treated some communities with suspicion all shape whether a person actually obtains a prescription .

The implications extend beyond HIV prevention. Both studies point to a broader question about how health policy is designed and evaluated. Medicaid expansion has been shown to increase HIV testing, linkage to care, and viral suppression—making it a key tool in the effort to end the HIV epidemic . But if the tool works better for some populations than others, the work of achieving equity is not finished when the policy is passed. It continues in the clinics, the community organizations, and the neighborhoods where the gap between availability and access is widest.

Two studies find that supportive state HIV prevention policies and Medicaid expansion increase PrEP access overall, but the greatest gains are observed among White populations. Black and Hispanic communities, which bear a disproportionate HIV burden, experience smaller improvements.

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Sources: Health Affairs, News-Medical, Rutgers Health, JoVE, medRxiv