Background
Racialized economic segregation significantly affects health outcomes by exacerbating disparities in disease prevalence and access to healthcare among marginalized communities. However, the impact of socioeconomic segregation on access to HIV pre-exposure prophylaxis (PrEP) across various socioeconomic groups remains unexplored in the US.
Methods
The Index of Concentration at the Extremes (ICE) quantifies segregation by measuring the concentration of individuals at opposite ends of the socioeconomic spectrum. Four ICE scores were calculated for >32,000 US Zip Code Tabulation Areas (ZCTAs) using American Community Survey data: race (White vs Black), income (high vs low), combined race/income (White/high-income vs Black/low-income), and education (high vs low). ZCTAs were categorized into quintiles, ranging from the most deprived (Q1) to the most privileged (Q5). PrEP prescription data and new HIV-1 diagnoses (2019–2023) were obtained from the IQVIA pharmacy claims database. Unmet PrEP needs were evaluated using the PrEP-to-Need Ratio (ratio of PrEP users to new HIV diagnoses from the previous year). Logistic regression was used to compare the odds of PrEP claims being dispensed in deprived versus privileged communities.
Results
Over 500,000 new PrEP prescriptions were linked with ICE indices. From 2019 to 2023, PrEP uptake increased steadily, but showed slower growth in deprived communities (predominantly Black and/or low-income, low-education neighborhoods). Unmet PrEP needs were greatest in the most deprived communities and lowest in the most privileged. Despite overall improvements, disparities driven by social segregation persisted, with the gap between Q1 and Q5 widening over time (Figure). In 2019, predominantly Black/low-income communities had 2.7 times greater unmet needs versus predominantly White/high-income communities; this ratio increased to 3.2 in 2023. Individuals in socioeconomically deprived communities were less likely to have PrEP claims dispensed versus those in privileged communities (odds ratios [95% CI] for combined race/income Q1 vs Q5 = 0.78 [0.77–0.79]; Q4 vs Q5 = 0.95 [0.94–0.96]).
Conclusions
This study highlights the significant association between racialized economic segregation and PrEP uptake, and the widening disparities in unmet needs for HIV prevention in the US. It is essential that efforts are targeted to reduce disproportionate unmet needs in marginalized communities and ensure equitable PrEP access across diverse populations in real-world settings.