Why the U.S. HIV epidemic persists despite PrEP breakthroughs

In theory, avoiding HIV in the United States should be easier than ever. But for Brenton Williams, the reality was far different.

Williams, whose fiancée is HIV positive, sought PrEP (Pre-Exposure Prophylaxis)—a daily pill or bimonthly injection that reduces HIV transmission risk by over 99% when taken as prescribed. He had completed all required lab work and a full physical, yet his doctor questioned the need for the medication. “Well, what do you need it for?” she asked, before suggesting she would “look into it.” Two months later, Williams still hadn’t received the prescription. “I don’t understand what the hold up is,” he said. “I definitely want to continue to have sex, but I also want to keep my body safe.”

Williams’ experience reflects a persistent gap between PrEP’s medical promise and its real-world accessibility. Despite FDA approval in 2012, barriers like provider hesitation, insurance gaps, and administrative delays continue to hinder uptake.

What is PrEP and who should take it?

PrEP is a preventative medication for people at risk of HIV, including those with:

• Multiple sexual partners
• A recent history of sexually transmitted infections
• Inconsistent condom use
• A history of drug use

It comes in two forms: a daily pill or a bimonthly injection. To start PrEP, patients must test negative for HIV and undergo additional screenings before receiving a prescription from a healthcare provider.

How much does PrEP cost?

For most Americans, PrEP is free or low-cost. Most insurance providers cover the medication, and assistance programs are available for uninsured patients. The CDC estimates that over 1.2 million Americans could benefit from PrEP, but only about 30% are currently using it.

PrEP’s role in ending the HIV epidemic

PrEP’s effectiveness is undeniable: when taken daily, it reduces HIV transmission risk by over 99% during sex with an HIV-positive partner. Meanwhile, antiretroviral therapy (ART) has transformed HIV from a fatal diagnosis to a manageable condition. People with HIV who maintain an undetectable viral load cannot sexually transmit the virus—a principle known as “U=U” (Undetectable = Untransmittable).

These advancements are a testament to modern medicine and the more than 700,000 Americans who have died from HIV-related causes since the epidemic’s first reported cases in 1981. Yet, despite these breakthroughs, the U.S. HIV epidemic persists. In 2022 alone, there were approximately 32,800 new HIV diagnoses in the country.

Why isn’t PrEP more accessible?

Experts cite several systemic barriers:

• Provider hesitation: Some doctors remain unfamiliar with PrEP protocols or reluctant to prescribe it.
• Insurance and administrative hurdles: Prior authorization requirements and coverage gaps delay access.
• Stigma and awareness gaps: Misconceptions about PrEP’s purpose or eligibility persist among both patients and providers.

Williams’ story underscores these challenges. “I just really wanted this extra layer of protection,” he said. “But I felt like I was fighting an uphill battle just to get the medication I needed.”

How to access PrEP

For those seeking PrEP, resources include:

• The HIV Services Locator (hiv.gov)
• The CDC’s PrEP Locator (gettested.cdc.gov)
• AIDSVu (aidsvu.org)
• Online providers like MISTR or state-run telePrEP programs

Experts argue that making PrEP as accessible as birth control—a daily pill with clear guidelines—could significantly reduce new HIV cases. Yet, until systemic barriers are addressed, the epidemic’s end remains out of reach for many.