Only 1 in 4 people who could benefit from HIV PrEP are currently taking it, and new data show that state policy is a meaningful driver of low uptake. This gap is driven by structural and social barriers, including limited access to healthcare, low awareness of personal HIV risk, and stigma related to engaging in sexual activity, particularly among those identifying as LGBTQ+. As a result, many individuals are less likely to seek HIV testing or discuss PrEP with a healthcare provider, contributing to persistent gaps in PrEP use, especially in young people and minority groups where the need for PrEP is greatest.
A recent study published in the Journal of Acquired Immune Deficiency Syndromes found that state-level LGBTQ+ policies negatively impact PrEP use in sexual and gender minority (SGM) individuals within the age groups needing it most (13-34 years of age)1. In states with more discriminatory policy environments, PrEP uptake is significantly lower, even after accounting for individual factors such as internalized stigma*. In fact, this study’s findings suggest that PrEP use would increase by as much as 14% if all states had less discriminatory policies, and would increase even more among Black individuals (up to 23%).
This study underscores how policy decisions directly shape individual health behaviors and outcomes. For clinics, this means that even when services are available, patients in more restrictive states may be less likely to initiate PrEP. These dynamics can show up as lower PrEP starts, more missed opportunities following HIV testing, and greater effort required to engage and retain patients in prevention programs.
Addressing structural barriers through inclusive policies and expanded access to care remains essential for advancing equity and reducing HIV transmission at the population level.This study also highlights the importance of program design. In more restrictive environments, passive access to PrEP is often not enough, and clinics benefit from models that reduce friction between testing, prescribing, and medication access.
Alchemy works with our clinic partners to build PrEP outreach and test and treat programs. By embedding pharmacy services within the clinic and enabling same-day PrEP starts, direct pharmacist follow-up, and adherence support, in-house pharmacy models can help offset some of the structural barriers highlighted in this study. For example, patients can begin PrEP immediately after testing rather than navigating an external pharmacy, reducing drop-off at a critical moment in care.
Of note, this study was a prospective cohort study that recruited participants from 2017-19 and followed them through 2022. However, in 2025 alone, over 600 bills aimed at LGBTQ+ groups were proposed across 22 states, and approximately 70 of those bills were enacted2. Thus, for the 85% of our partnering clinics operating in restrictive policy environments, the work to get PrEP into the hands of people who need it is only getting harder.
While policy change is critical, this study makes clear that clinics cannot rely on policy environments alone to drive PrEP uptake. Program design, specifically how easily patients can start and stay on PrEP, plays a central role. As the policy landscape continues to evolve, investing in integrated, low-friction PrEP delivery models will be essential to closing the gap.
Please check out your own state laws on the Movement Advancement Project (MAP) website-, and advocate for changes both locally and nationally.
*Internalized stigma is the internalization of judgements or societal beliefs around sexual activity and preferences, leading to the belief that “something is wrong with me”.
Citations
1. Kelly NK, Ranapurwala SI, Pence BW, et al. The Effect of State-Level Policy Climate on HIV Pre-Exposure Prophylaxis Use and the Role of Internalized Stigma. J Acquir Immune Defic Syndr. 2026;101(1):69-76.
2. Adamczeski, Adam. ‘22 states that have passed anti-LGBTQ+ laws in 2025 so far.’ Advocate. 3 November 2025. https://www.advocate.com/politics/anti-lgbtq-laws-states-2025#rebelltitem22
