Modest Reductions in PrEP Coverage Result in Avoidable HIV Infections

Avoidable HIV infections and net health care costs would rise if coverage of pre-exposure prophylaxis (PrEP) were to be reduced even a moderate amount, according to a study published in JAMA Network Open.¹ Policy changes in the US could lead to such results if government officials continue to push for reduced capacity to prevent HIV.

Incidence of HIV and cost of health care would go up if coverage of PrEP is reduced | Image credit: alimyakubov - stock.adobe.com

The risk of acquiring HIV is reduced by 99% when individuals use PrEP as directed, but only 36% of those in the US who had indications for PrEP were actively using it. Availability of PrEP is a factor in the uptake of the medication as well as affordability. Recent moves from the Trump administration have introduced cuts to HHS and Medicaid through administrative and legislative means.² This has been paired with cuts to research related to HIV,³ which have put PrEP coverage and availability into question. This study aimed to assess what the effects of these cuts would be in terms of incidence of HIV and costs of infections that were not prevented.

Parameters from a recent model were used to estimate the association between changes in PrEP coverage and incidence of HIV. This analysis specifically assessed the impact of policy changes on the decreased use of PrEP. The original model was used for its data, with the researchers reversing the sign of the negative parameter estimate for this study to estimate any increases in diagnoses. The original model also provided the comparator scenario, using data from 2012 to 2022. The diagnosis of HIV for 1 per 100 persons decrease in the coverage of PrEP was calculated for a predicted percent increase.

The model was applied to a first scenario where all increases in PrEP coverage were reversed over the course of a decade, a second scenario where absolute annual decreases equaled 10%, and a third scenario where the annual decreases were 2%. Current costs of treatment for HIV were used to calculate costs that would arise due to HIV infections that PrEP did not prevent.

There were 9565 individuals in the US who were using PrEP in 2012, of which 61.2% were men and 56.5% were non-Hispanic White. The model assumed that PrEP coverage would be reduced by 3.3 per 100 individuals with indications for PrEP per year for the next decade. This would lead to a mean increase of diagnoses of HIV that equaled 2.3% (95% CI, 2.2%-2.4%) per year. Should this come to pass, this would reverse the reductions in HIV transmissions that have been achieved between 2012 and 2022.

The researchers estimate that there would be 8618 new infections of HIV that could have been avoided and a discounted lifetime medical cost of $3,622,016. The discounted net cost of this increase of HIV infections would be $1,430,864,206. A yearly decrease of coverage for PrEP of 10 per 100 individuals resulted in 26,873 new HIV infections, and a discounted lifetime medical cost of $11,294,318,805.

There were some limitations to this study. The associations between levels of PrEP and HIV infections were estimated using an experimental approach. The researchers used a simplistic assumption to estimate that PrEP use would decline by 3.3% per year as the base case. There are no previous models to use to estimate the withdrawal of funds due to the unprecedented nature of these funding cuts. Behaviors are not as independent to PrEP status and adherence as this analysis presumed. Trends in HIV diagnoses can also rely on other aspects of PrEP delivery, such as interventions. Other factors were not calculated in the analysis.

“We estimated that even modest decreases in coverage of PrEP would have substantial negative effects on health, manifested as increases in new HIV infections and associated health care costs,” the authors concluded. “Such changes in coverage would be the expected results of disinvestment in HIV prevention activities or policy changes that discourage PrEP use by taking away existing health care coverage, increasing out-of-pocket costs for PrEP, or increasing barriers to HIV screening…”

References

1. Sullivan PS, Wall KM, Juhasz M, et al. Excess HIV infections and costs associated with reductions in HIV prevention services in the US. JAMA Netw Open. 2025;8(9):e2531341. doi:10.1001/jamanetworkopen.2025.31341

2. Shaw ML. Proposed GOP Medicaid cuts threaten loss of coverage for millions. AJMC^®. May 12, 2025. Accessed September 17, 2025. https://www.ajmc.com/view/proposed-gop-medicaid-cuts-threaten-loss-of-coverage-for-millions

3. Bonavitacola J. Cuts to HIV vaccine research come amid challenges to other vaccines, treatment. AJMC. June 13, 2025. Accessed September 17, 2025. https://www.ajmc.com/view/cuts-to-hiv-vaccine-research-come-amid-challenges-to-other-vaccines-treatment