The study authors note that additional policies to reduce structural stigma against sexual minorities could continue to improve the rate of individuals who initiate PrEP use.
Although pre-exposure prophylaxis (PrEP) is an efficacious method of reducing HIV infections, structural stigma against sexual minorities, such as men who have sex with men (MSM), may affect PrEP implementation. State-level policies against these populations are especially obstructive against individuals looking to begin PrEP. A study published in the Journal of International AIDS Society expands on previous work using PrEP prescription data to evaluate potential associations between the timing of same-sex marriage policies in the United States with PrEP implementation among this population. The authors specifically evaluated whether states that implemented same-sex marriage policies earlier had a higher uptake in male PrEP prescriptions.
The study uses AIDSVu data on male PrEP prescriptions and male PrEP-to-need ratio (PnR) in each US state from 2012 to 2019. AIDSVu PrEP data contains the most comprehensive information on PrEP prescriptions, including data from pharmacies, hospitals, outpatient facilities, physician practices, and clinics. In addition, the dataset includes state-specific upweighting of PrEP prescriptions that accounts for underestimates that are a result of misclassified prescriptions.
The main outcome of interest was the rate of male PrEP use per 100,000 males aged 13 years or older in each state and year, and the secondary outcome of interest was male PnR. Further, the dataset does not contain information on race, ethnicity, sexual orientation, or gender identity of those who receive prescriptions. Adjustments were made as needed for the calendar year, Medicaid expansion, and the political party of the governor in each state.
Samples were limited for all analyses to people who indicated male sex. Although PrEP is indicated for any males who have sex partners of unknown HIV status and do not always use protection during intercourse or who are people who inject drugs (PWID), prior analyses show that male PrEP users are predominantly MSM. Even though PrEP is an effective approach to preventing HIV for PWID, other analyses indicate that PrEP use is low among this population.
In the analysis, there were 7 states which had implemented same-sex marriage before 2012, 10 states in 2012 to 2013, and 33 states in 2014 to 2015. The first states to implement same-sex marriage were more likely to be in the Northeast, whereas states that implemented same-sex marriage in the 2012 to 2013 period or the 2014 to 2015 period were in each US region. From 2012 to 2019, there were increases in the male PrEP prescription rate across all 50 states, with prescriptions per 100,000 people increasing from a mean of 4 in 2012 to a mean of 151 in 2019 (36 per 100,000 in Wyoming to 352 per 100,000 in New York). Compared to 2014 to 2015 (119.8), prescription rates were much larger in states that implemented same-sex marriage between 2004 and 2011 (238.8) and 2012 to 2013 (168.3).
In addition, linear analyses of PnR showed that implementing state same-sex marriage policies between 2004 and 2011 (PnR: 1.26, 95% CI: 0.15-2.36) and between 2012 and 2013 (PnR: 3.83, 95% CI: 2.84-4.81) were each associated with a greater male PnR relative to implementing same-sex marriage policies between 2014 and 2015. By 2019, there was a positive correlation present between new HIV diagnoses and PrEP prescriptions per 100,000 males. The increase in male PrEP prescriptions per increase in HIV diagnoses was larger in states that implemented same-sex marriage policies between 2004 and 2011 (17.2, 95% CI: 12.2-22.2) compared to states that implemented same-sex marriage policies in 2014 to 2015 (2.0, 95% CI: 0.0-2.9). Although there was an association between new HIV diagnoses per 100,000 males and PrEP prescriptions per 100,000 males in states that implemented same-sex marriage in 2012 and 2013, it was relatively insignificant (3.6, 95% CI: -3.3 to 10.5), according to the study authors.
The study authors note that structural stigma at the time of PrEP introduction could have potentially influenced early investments in PrEP implementation. Therefore, earlier adoption of same-sex marriage policies could reflect state-level policy climates affecting minorities. However, implementing same-sex marriage policies alone was insufficient to bridge the gap in PrEP prescription among states who implemented policies later.
In addition, the positive association between new HIV diagnoses and PrEP prescriptions in 2019 suggests that PrEP reached states with higher HIV needs, notably in those with earlier same-sex marriage implementation; however, the correlation was stronger in states that adopted same-sex marriage earlier, which indicates the need for increased PrEP implementation as well as structural support—such as Medicaid expansion—in states with the highest rates of new HIV diagnoses.
Limitations of this study include the lack of information on patient race, ethnicity, sexual orientation, and gender identity (eg, individuals assigned male at birth who identify as transgender women), and the lack of individual-level identifiers, leading to difficulty accounting for within-person correlation for those with PrEP prescriptions in multiple years. Further, precise information on the population denominator of MSM varies by state; therefore, there could be inconsistencies in the data. The study authors suggest that future research could explore the relationship between sexual minority rights and PrEP use by race and ethnicity, as well as how structural stigma and racism affect these populations.
Raifman, J, Cheng, DM, Skinner, A, Hatzenbuehler, ML, Mayer, KH, and Stein, MD. State same-sex marriage policies and pre-exposure prophylaxis implementation among men who have sex with men in the United States. J Int AIDS Soc. 26:e26180. doi:10.1002/jia2.26180