Medicaid expansion under the Affordable Care Act (ACA) substantially increased access to preexposure prophylaxis (PrEP) among people at heightened risk of an HIV diagnosis, according to a new Rutgers Health–led analysis published in Health Affairs.
The research examined PrEP prescription data from all 50 states and Washington, D.C., spanning 2012 to 2023. Across the country, PrEP use rose steadily, and prescriptions increased relative to the number of new HIV diagnoses. Researchers suggest the trend reflects both broader access to PrEP and a nationwide decline in new infections.
However, gains were not evenly distributed. White Americans saw much larger increases in PrEP prescribing than Black, Hispanic, and Latino populations—groups that continue to experience disproportionately high HIV diagnosis rates.
“Medicaid expansion is a powerful tool for improving HIV prevention,” said lead author Elizabeth Stone of the Rutgers Center for Health Services Research. “But the disparities we observed underscore the need to intentionally address barriers limiting PrEP access for Black and Hispanic communities.”
The Centers for Disease Control and Prevention reports roughly 35,000–40,000 new HIV infections each year in the United States. Only an estimated 36% of people who could benefit from PrEP currently receive it. The racial divide is stark: in 2022, 94% of eligible white Americans received a PrEP prescription compared with 13% of Black Americans and 24% of Hispanic and Latino Americans. Common PrEP options include Truvada, Descovy, and long-acting injectable formulations.
Medicaid expansion, available to adults with incomes up to 138% of the federal poverty level, has been adopted by 40 states and Washington, D.C. But researchers warn the progress linked to expansion could erode. The One Big Beautiful Bill Act, signed into law in July, removes enhanced federal funding for expansion populations and introduces new coverage barriers such as work requirements and more frequent eligibility checks. The Congressional Budget Office estimates that 7.5 million people could lose Medicaid coverage over the next decade.
In the study, the largest increases in the ratio of PrEP prescriptions to new HIV diagnoses occurred among men, adults aged 25 to 34, and white populations. Black, Hispanic, and Latino groups showed smaller gains despite facing a higher burden of new infections.
“These disparities highlight the limitations of relying solely on state-by-state insurance expansion to close gaps in HIV prevention,” Stone said. “We need policy approaches that address the social and systemic drivers of inequitable PrEP access.”
Coauthors included Nicholas Seewald of the University of Pennsylvania and Joseph Rosen of Rhode Island Hospital.
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