Background
Despite high efficacy of pre-exposure prophylaxis (PrEP) for HIV prevention, uptake is low among cisgender women in the US, especially in the South where >50% of new HIV diagnoses occur. The Ending the HIV Epidemic (EHE) initiative prioritizes 57 jurisdictions for targeted HIV prevention and treatment interventions. To identify opportunities for optimizing HIV prevention in women, we (i) evaluated whether designated EHE jurisdictions geographically overlap with counties of highest female-to-male HIV prevalence and (ii) assessed opportunity for PrEP uptake in these areas.
Methods
We used AIDSVu 2021 data to estimate female-to-male HIV prevalence ratios (PR) at the county level and in all EHE jurisdictions. For HIV prevalence, we included counties if the population was >500 persons and HIV prevalence >12 cases, and excluded if the county contained any correctional facilities. For PrEP data, we included counties if population was >100 persons and number of PrEP users was >3. For entire states specified as an EHE jurisdiction, every county in that state that met criteria for analysis was categorized as EHE-designated. Counties were ranked by female-to-male HIV PR, categorized by decile, and then we tested for discrepancies in EHE designation status and availability of PrEP utilization data between top vs bottom decile counties using a chi-square test.
Results
A total of 870 US counties (including Puerto Rico) met inclusion criteria (Figure). Of the top decile counties, female-to-male HIV PR ranged from 0.58-1.36, and 80% were located in the South. Of the bottom decile counties, female-to-male HIV PR ranged from 0.07-0.19, and 25% were located in the South. Comparing top vs bottom decile counties, 23 (26%) vs 22 (26%) were EHE-designated (p=0.89), however, nine (9%) vs 67 (79%) had available PrEP utilization data (p<0.0001). PrEP data availability were primarily limited by low or nonexistent PrEP users.
Conclusions
Using AIDSVu data, in 2021, 80% of U.S. counties with the highest ratio of female-to-male HIV prevalence were located in the US South. While EHE jurisdiction status at the county level did not significantly differ between top vs bottom decile counties, there were limited PrEP data available in regions of highest female-to-male HIV prevalence, primarily due to low PrEP uptake in these areas. As the biomedical toolkit for PrEP options expands, it is critical to optimize HIV prevention reach, use, and outcomes using geographically- and sex and gender-tailored approaches.