Demographic, clinical guideline criteria, Medicaid expansion and state of residency: a multilevel analysis of PrEP use on a large US sample

BMJ Open. 2022 Feb 2;12(2):e055487. doi: 10.1136/bmjopen-2021-055487.


Objective: To explore the association of clinical guideline-related variables, demographics and Medicaid expansion on pre-exposure prophylaxis (PrEP) uptake in one of the largest US sample of men who have sex with men(MSM) and transgender and gender non-binary (TGNB) people ever analysed.

Methods: We cross-sectionally analysed predictors of current PrEP use using demographic and HIV risk-related variables (level-1), as well as state-level variables (level-2) (ie, Medicaid expansion status). We further explored the role state of residence plays in PrEP uptake disparities across the USA.

Results: We found that the odds of PrEP use were significantly greater in older age, white, cisgender men. Moreover, individuals who reported recent post-exposure prophylaxis use, a recent sexually transmitted infection diagnosis and recent drug use were significantly more likely to report PrEP use. Finally, we found that the median odds of PrEP use between similar individuals from different states were 1.40 for the ones living in the Medicaid expansion states, compared with those not living in Medicaid expansion states. State of residence did not play a significant role in explaining PrEP disparities overall.

Conclusion: Our analysis showed that PrEP use is less common in communities standing to benefit the most from it-young MSM and TGNB of colour. However, individuals meeting federal guidelines for PrEP were significantly more likely to use PrEP. Though we found a positive association between living in Medicaid expansion states and PrEP use; that variable, as well as one's state of residency, were not suitable to explain variations in PrEP use in the US.

Keywords: HIV & AIDS; epidemiology; preventive medicine; public health.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Anti-HIV Agents* / therapeutic use
  • Demography
  • HIV Infections* / drug therapy
  • HIV Infections* / epidemiology
  • HIV Infections* / prevention & control
  • Homosexuality, Male
  • Humans
  • Internship and Residency*
  • Male
  • Medicaid
  • Multilevel Analysis
  • Pre-Exposure Prophylaxis*
  • Sexual and Gender Minorities*
  • United States


  • Anti-HIV Agents