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News|Articles|October 15, 2026
FAQ: How Payers Can Close HIV Prevention and PrEP Access Gaps
Author(s)Sabrina McCrear
Fact checked by: Ashley Gallagher, MA
On National Latinx AIDS Awareness Day, experts outline HIV prevention gaps in Hispanic communities and how payers can ease PrEP access.
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National Latinx
An estimated 1.2 million people are living with HIV in the US, and gay and bisexual men accounted for 79.8% of new HIV diagnoses in 2024.2,3 Within this population, Hispanic or Latino and Black and African American gay and bisexual men received more new diagnoses than gay and bisexual men in other groups.3 Yet only 36% of people who could benefit from
Clinicians and health organizations are working to close gaps in care, education, and awareness, but payers and other stakeholders also have a role to play, from supporting tailored messaging to reevaluating utilization management requirements such as prior authorization and step therapy.
Here are 3 FAQs for payers and health systems on the current barriers to HIV prevention and care and where improvements can be made.
Which Groups Face the Widest Gaps in HIV Testing, PrEP, and Care?
Hispanic and Latino communities in the US are diverse, representing a range of education levels, incomes, languages, and cultures. Those who are recent immigrants, have completed less formal education, or have limited English proficiency are disproportionately affected by HIV and may be at a disadvantage when accessing HIV testing, prevention, and treatment services.1
Black women are another group facing disproportionate risk. Women represent 19% of all new HIV diagnoses in the US, and in 2023, Black women accounted for 50% of new HIV diagnoses among women despite making up only 13% of the female population.4
Young men aged 13 to 24 years with HIV are also more likely to be unaware of their HIV status than men in other age groups.3
Racism, discrimination, and stigma contribute to these disproportionate impacts.3 Stigma surrounding HIV and PrEP is especially prevalent in underserved communities where the population may be primarily Black or Hispanic, and experts have called for trusted messengers who can deliver tailored messaging within those communities.2
Who delivers that message matters, Christina Madison, PharmD, FCCP, AAHIVP, a public health expert and clinical pharmacist, said in an interview with The American Journal of Managed Care® (AJMC®). Health systems often fall short when the person delivering information is not part of the community they are trying to reach, she said.
"Because if I see someone that looks like me, if I see someone that has a similar lived experience, I'm much more likely to take that medical information vs if it's someone that I feel like just doesn't understand where I'm coming from," Madison said.
How Do Prior Authorization and Step Therapy Limit PrEP Access?
Clinicians and pharmacists frequently cite prior authorization, particularly step therapy, as a barrier to long-acting PrEP. Some payers require patients to try oral PrEP before covering long-acting injectable options.
In effect, patients must fail oral PrEP first, but failing PrEP generally means a patient has been put at increased risk for HIV, Kevin Astle, PharmD, BCPS, BCACP, AAHIVP, CDCES, assistant professor in the Department of Pharmacotherapeutics and Clinical Research at the University of South Florida Taneja College of Pharmacy, said in an interview with AJMC. Some patients may also be unable to take oral options because of kidney or bone mineral density concerns, he added.
"As we're working with different policymakers and advocacy groups, we really want to see where insurance companies are covering all forms of PrEP, without requiring any potential step therapy," he explained.
Federal HIV treatment guidelines note that commercial insurers and state Medicaid programs apply utilization management tools such as prior authorization, step therapy, and formulary restrictions, while Medicare Part D prohibits prior authorization and step therapy for antiretrovirals. Given the risks of viral rebound, drug resistance, and increased transmission associated with treatment delays, the guidelines advise that these tools be applied cautiously.5
How Are Long-Acting HIV Therapies Changing Costs and Adherence?
HIV care remains costly in the US. Medicaid spent $25 billion on antiretroviral drugs from 2007 through 2019, with annual spending climbing 178%, from $1.1 billion to $3.0 billion. Among Medicare beneficiaries, total spending for people with HIV on treatment was 221% higher than for those without HIV, driven largely by drug costs.5
List prices for long-acting injectable cabotegravir/rilpivirine for HIV treatment are comparable to common daily oral regimens on an annual basis, but injectables carry added costs, including clinic visits, administration fees, and prior authorization requirements.5
Long-acting options may offer the greatest value for people who struggle with daily pills. In the LATITUDE trial, which enrolled adults with HIV who had difficulty adhering to daily oral treatment, treatment failure occurred in 22.8% of participants receiving monthly injectable cabotegravir/rilpivirine vs 41.2% of those continuing daily oral therapy.6
Prevention can also offset the long-term cost of treatment, Astle said.
"The cost for the medications may seem high up front, but really when we look at the cost of any new HIV infections, from a monetary perspective, it's going to be extremely more expensive," he said.
Looking Ahead
National Latinx AIDS Awareness Day is a reminder that the disparities facing Hispanic and Latino communities, and other groups disproportionately affected by HIV, remain a pressing concern for payers and health systems.
Closing these gaps will require more than effective medications. It will take culturally and linguistically responsive outreach led by trusted messengers, coverage policies that do not force patients to fail one form of prevention before accessing another, and continued investment in long-acting options for patients who struggle with daily regimens.
For payers, easing utilization management barriers to prevention now may reduce the far greater clinical and financial burden of new HIV infections later.
References
1. National Latinx AIDS Awareness Day. NIH. Accessed September 28, 2026.
2. McCrear S. National HIV testing day highlights expanding PrEP, PEP access, persistent barriers. AJMC. June 27, 2026. Accessed September 28, 2026.
3. National Gay Men's HIV/AIDS Awareness Day, September 27. NIH. Accessed September 28, 2026.
4. McCrear S, Tims-Cook Z. Why Black women face higher HIV risk, lower PrEP access. AJMC. September 1, 2026. Accessed September 28, 2026.
5. Cost considerations and antiretroviral therapy. In: Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents With HIV. NIH. Updated September 24, 2026. Accessed September 28, 2026.
6. Pieters K. Monthly HIV injections more effective than daily pills for people struggling with treatment adherence. CU Anschutz. March 13, 2026. Accessed September 28, 2026.
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