Use of preexposure prophylaxis (PrEP) for HIV prevention in adolescents and young adults is “strikingly low,” though youth aged 13-24 years have nearly 1 in 5 new HIV infections in the US, according to a new study in JAMA Pediatrics. Use is particularly low in women and young people who live in the South and Midwest.

“Efforts to expand PrEP use among youths should address geographic disparities, legal and policy barriers, and clinician engagement to improve equitable access to HIV prevention,” the authors wrote, led by Nicholas Venturelli, MD, MPH, with Boston Children’s Hospital in Boston.

In a cohort study of 100,536 youths aged 13-21 years with commercial insurance and who had a documented sexually transmitted infection (or high-risk sexual behavior), only 1598 (1.5%) filled a PrEP prescription, the data showed. PrEP use was significantly higher in older youths (aged 20-21 years vs younger than 18 years), males, and those living in states with LGBTQ+ protective laws. Males who filled a prescription also started use earlier than their female counterparts (median, 38 days vs 227 days; P < .001).

Participants were followed from date of PrEP indication until PrEP prescription fill, insurance disenrollment, or HIV diagnosis.

Gap Pronounced for Younger Than 18 Group

Those younger than 18 years may face particular challenges. While PrEP prescriptions for those younger than 20 years increased by 78% in the US from 2018 to 2021, the authors noted, the rise was largely in 18- to 19-year-olds, and the use remained minimal in those younger than 18 years.

PrEP use was notably low in males in the younger than 18 group, and the authors explained that may be driven by men who have sex with men who ask for PrEP after turning 18. “These disparities may be driven by complex factors for minors, including concerns about parental disclosure, limited pediatrician knowledge, lack of preventative care visits, and the transition from pediatric to adult care,” the authors wrote.

Those younger than 18 years also had the longest delays in receiving PrEP after the first diagnosis, suggesting they would benefit from PrEP (median, 222 days vs 60 days among those aged 18-19 years and 35 days for those aged 20-21 years; P < .001).

Few Pediatricians Prescribe PrEP

Pediatricians, the researchers found, represent only a small fraction of PrEP prescribers for the cohort they studied, but care for many who would benefit from PrEP.

“Confidential conversations with adolescents are essential,” the authors wrote. “[Y]et more than half of youths report not having had time alone with a healthcare professional. Additionally, pediatricians require more training in sexual health screening and PrEP counseling; more than 50% report never discussing PrEP with their patients.”

Pediatricians may be hesitant to start PrEP conversations for several reasons, said Julia Rosebush, DO, associate professor in the Department of Pediatrics, Section of Infectious Diseases at The University of Chicago in Chicago. Among them is that even though conversations can be held privately, the patient likely is covered through their parents’ insurance and medical information about visits may go to them. Also, states differ on emancipation age, when an adolescent is considered an adult from the sexual health perspective, she told Medscape Medical News.

“I think providers think about that and are more hesitant because of the implications of prescribing to a younger minor,” said Rosebush, who was not part of the study.

Nevertheless, she said, these data emphasize the need for pediatricians and primary care providers to intervene to prevent HIV.

“Pediatricians, particularly those in the community, are in a prime position to be able to help. If we leave PrEP prescription only to adult providers or only to infectious disease providers, we will never be able to see what power PrEP could have on the potential decrease in new HIV infections,” she said.

Rosebush said, medicine also needs to look beyond MDs and DOs to help facilitate talking with young people about sexual behaviors. “People respond to people who look like them and have had similar experiences,” she said.

Adult-Centered Models May Miss Key Group

“Adolescents and young adults represent a critical inflection point in the US HIV epidemic, yet existing systems continue to rely on adult-centered models that inadequately address the structural, policy, and developmental contexts shaping youth engagement,” Rahim Z. Miller, with the Institute on Digital Health and Innovation, College of Nursing at Florida State University in Tallahassee, Florida, and colleagues wrote, in an accompanying viewpoint.

Among some challenges to care are housing instability, lack of transportation, and navigating child welfare and juvenile justice systems where continuity of care is difficult. Integrating HIV services with housing support, behavioral healthcare, and transportation assistance would help, they suggested.

In addition, embedding medical-legal partnerships within healthcare can help address the barriers, they wrote.

“Through medical-legal partnerships, youth can access assistance related to support for housing, benefits, referral coordination, immigration, and family law, issues that often determine whether prevention and treatment services are accessible and sustainable,” they wrote.

A study co-author Douglas Krakower, MD, received grants from the Harvard University Center for AIDS Research during the study; grants from Gilead Sciences and Merck; personal fees from Medscape Medical News and UpToDate, Inc.; and travel support from PrEP4All outside the submitted work. Rosebush and the editorialists reported having no relevant financial relationships.

Marcia Frellick is an independent healthcare journalist and a regular contributor to Medscape Medical News.