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Adolescents and young adults (AYA) 13 to 24 years old in the United States make up approximately 20% of all new HIV diagnoses and have some of the highest rates of sexually transmitted infections, highlighting the clear need for HIV prevention in this age group.1,2 Because there are many challenges to HIV prevention, it is important to consider youth-specific systemic interventions. Pre-exposure Prophylaxis (PrEP) is an essential component of the HIV prevention toolkit and an important component of the national “Ending the HIV Epidemic” (EHE) initiative and National HIV Strategy.3
In this issue of Pediatrics, Kimball and colleagues describe estimates of adolescents prescribed PrEP.4 Using a national pharmacy database (the IQVIA Real world database), they evaluated changes in PrEP prescriptions for adolescents 13 to 19 years old between 2018 and 2021 by sex, age group, urban or rural setting, US region, and prescriber. The study found an overall 76.2% increase in prescriptions over the time period. It is encouraging that prescribing rates have increased yearly, with the exception of 2020, which was likely affected by coronavirus disease 2019. Most adolescents prescribed PrEP in 2021 were male (82.6%) and aged 18 to 19 years (87.8%), with the most noticeable increase in prescription patterns occurring among those older adolescents. Among the PrEP prescribers, 29.6% were pediatricians. Important study limitations include lack of data on race and ethnicity, gender and sexual identity, HIV risk factor, and change in prescriber practice over time. These limitations are notable given the persistent disparities seen in HIV acquisition among minoritized communities (eg, Black, gay) discussed below.
The study and its findings highlight current prescribing trends and inform future directions to optimize the PrEP continuum among AYA to meet the EHE initiative goals.3,5 PrEP awareness and prescribing is low among providers in general, and among pediatric providers, specifically.6 Pediatric providers often see patients through age 21 and have a unique lens into their development, including their evolving sexuality, providing them with an opportunity to introduce and normalize conversations about sexual health, risk reduction, and sexually transmitted infection and HIV prevention, including PrEP.7 The US Department of Health and Human Services guidelines for PrEP highlight that providers should evaluate all adolescent and adult patients who are sexually active and offer PrEP to those whose sexual practice and history places them at substantial risk of acquiring HIV infection.8 Despite this, PrEP knowledge and adherence concerns can be barriers for PrEP prescribing for AYA providers.9 Although it is encouraging that 29% of prescribing physicians were pediatricians, what is not known are the numbers of missed opportunities to discuss HIV prevention and prescribe PrEP. There is a need to increase knowledge of PrEP among pediatricians and empower them to discuss and prescribe PrEP for adolescents at high risk of HIV acquisition.10 Multiple educational resources exist for clinicians.11,–13
A disparate proportion of the new HIV infections among AYA occur among young men from racially and ethnically minoritized communities in the United States, particularly among those living in the southern United States and other high-prevalence locales.1 Among adult men who have sex with men (MSM), there are racial disparities in PrEP prescribing with Black and Hispanic MSM, with less PrEP use compared with white MSM.14 Among women, there are also racial and ethnic and age disparities in HIV acquisition and PrEP, with younger, Black women being at higher risk and having low PrEP knowledge and uptake, respectively.15,16 Though not available in this study, data on inequities by race and ethnicity in PrEP prescribing for AYA is essential for the development of effective initiatives. Such data will inform whether those at highest risk of acquiring HIV are also receiving the benefit of the prescriptions. The regional data in the study show that the largest increase in adolescent PrEP occurred in the South, which is a hopeful signal that uptake is happening in the locales where PrEP need is highest.1
The study found that most (87.8%) of AYA prescribed PrEP were 18 to 19 years old. In the PrEP demonstration trials that resulted in approval for adolescents, 15 to 17-year-olds had higher rates of seroconversions (6.4 per 100 person-years) than 18 to 22 year olds.17,18 Intentional efforts are needed to expand PrEP to younger adolescents at risk for HIV acquisition.
Although low prescribing is a barrier, once prescribed, youth face barriers to PrEP adherence. In the aforementioned PrEP demonstration trial, 41% of 15 to 17-year-old MSM discontinued their PrEP prematurely, with the discontinuations associated with decreased frequency of required study visits as directed by the protocol.17 A critical component of future analyses would be data on PrEP persistence to garner an understanding of which patients begun on PrEP and continue to be at-risk, continue taking PrEP. This data will be important in delineating the role of other modalities, such as cabotegravir, the first injectable PrEP (administered every 2 months), which may be critical in addressing the adherence and persistence issues for youth.19
Even with these limitations identified, the investigators should be congratulated on their efforts to understand current PrEP uptake among adolescents and the role of prescribing providers in that uptake. The findings of marked increase in PrEP prescriptions between 2018 and 2021 show that efforts to increase PrEP uptake among adolescents are taking root. However, there are the aforementioned opportunities to improve data collection to inform the design and implementation of initiatives to further increase uptake. These lessons learned will be critical as other modalities (eg, long-acting injectable PrEP), which can minimize delays in uptake and optimization, become available for HIV prevention in youth. In summary, proving clear data are power; the current study by Kimball et al is a first critical step to realize the goal of improving the role of PrEP in HIV prevention for adolescents.
Drs Griffith and Agwu contributed equally to drafting and revising the manuscript; and both authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
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