State HIV prevention policies help white adults most, study finds

State policies designed to make HIV prevention easier to access and to shield LGBTQ+ people from discrimination appear to deliver their benefits unevenly, according to a new study from researchers at the University of Pennsylvania. The analysis, published in the journal AIDS and Behavior, found that supportive state policy environments were associated with greater use of HIV prevention measures among white adults, but that those associations were significantly weaker, or absent, among Black and Latino participants. The finding lands with particular force because Black and Latino communities continue to carry the highest HIV incidence rates in the United States and remain priority populations in the federal initiative to end the domestic HIV epidemic.

The research team, led by Bita Fayaz Farkhad, an assistant professor at the University of Arkansas for Medical Sciences and a former assistant research professor at the University of Pennsylvania’s Annenberg School for Communication, set out to answer a deceptively simple question: do state policy environments actually shape whether people use the prevention tools that science has made available? To do so, the investigators catalogued 35 HIV-related state policies and linked these state-level data with a national survey of 1,041 men who have sex with men and transgender women, the groups most affected by the American epidemic. The outcomes they examined were three of the most consequential measures in HIV prevention: use of pre-exposure prophylaxis, or PrEP, the daily medication that reduces the risk of acquiring HIV through sex; HIV testing within the past year; and willingness to receive an HIV vaccine if one becomes available.

Rather than treating each law as an isolated variable, the researchers grouped the 35 policies into three broad categories that reflect distinct theories of how policy influences health behavior. The first category comprised supportive, access-focused policies, including measures that allow pharmacy-based PrEP delivery, protect access to transgender healthcare, and reduce insurance barriers. The second comprised supportive, attitude- or norm-focused policies, which are intended to increase social acceptance of LGBTQ+ populations and include nondiscrimination protections based on sexual orientation or gender identity, hate crime laws, and protections against bullying. The third category comprised punitive policies, such as HIV criminalization laws and restrictions on LGBTQ-related discussions in schools. This grouping allowed the team to ask whether the social climate created by law, the practical access created by law, or the punitive shadow cast by law was most closely tied to prevention behavior.

The policy landscape the researchers mapped varied substantially across the country. Supportive access-focused policies and supportive attitude- or norm-focused policies were more common in the West and the Northeast, while punitive policies were more prevalent in the South and the Midwest. That geographic split matters because it overlaps with the regional distribution of HIV itself: the American South has long accounted for a disproportionate share of new diagnoses, and the new findings suggest that the states where prevention need is greatest are also the states where supportive policy environments are thinnest and punitive approaches most common.

When the researchers examined the relationship between policy environments and prevention outcomes, a clear and troubling pattern of racial and ethnic differences emerged. Among white participants, more supportive policies aimed at reducing discrimination and increasing social acceptance of LGBTQ+ populations were associated with greater PrEP use, and more supportive access-focused policies were associated with a greater likelihood of having had a recent HIV test. Among Latino participants, however, the association between discrimination-reducing and acceptance-promoting policies and PrEP use was significantly weaker than it was for white participants. Among Black participants, the associations between both types of supportive policies and HIV testing were significantly weaker than among white participants. In other words, the very policies that should, in principle, raise prevention uptake most where need is highest appeared to translate into measurable behavior change primarily for white respondents.

The authors are careful about what this pattern does and does not mean. The study identifies associations between policy environments and preventive outcomes; it cannot establish what is cause and what is effect. The analysis relied on policies in place as of January 2024 and did not track whether changes in policies were followed by changes in prevention outcomes over time. Investigating the impact of policy changes directly is the team’s stated next step. Even so, the researchers argue, the direction of the disparity is concerning on its face, because policies designed to increase social acceptance of and reduce discrimination against LGBTQ+ populations should be effective among ethnic minority groups, and the populations with the greatest HIV incidence should see the largest gains in testing and PrEP use.

Additional analyses offered a clue about why supportive policies may fall short. White participants living in states with supportive policies reported that they could obtain healthcare and perceived that the people around them supported HIV prevention. The analyses did not show the same pattern among Black or Latino participants. One possible explanation, the researchers suggest, is that medical infrastructure in historically marginalized communities may remain under-resourced, preventing supportive policies from translating into effective access to HIV prevention services on the ground. A state law permitting pharmacy-based PrEP delivery, for example, matters little in a county without a participating pharmacy or a provider willing to prescribe. Stigma and other structural barriers may also play a role, dampening the effect of legal protections even where they formally exist.

“Supportive state policies are an important foundation for HIV prevention, but our findings raise questions about whether those policies are sufficient to meet the prevention needs across communities,” said Farkhad. “We need to understand what prevents Black and Latino communities from accessing prevention services, for example, whether people can find a healthcare provider who offers PrEP or a convenient place to get an HIV test.” The quote underscores a central tension in prevention science: legal environments set the conditions under which individuals can act, but the final step, walking into a pharmacy, clinic, or testing site, depends on local capacity and community trust that legislation alone cannot supply.

“Adopting policies that theoretically improve people’s access and comfort seeking PrEP is only part of the challenge,” said Dolores Albarracín, the study’s senior author, a University of Pennsylvania PIK Professor and director of the Annenberg Public Policy Center, where the Social Action Lab that conducted the work is based. “We also need to understand whether those policies actually translate into greater access to HIV prevention in the most vulnerable communities. This analysis suggests they fall behind. At a time when research on these topics is restricted, our study reminds us of the implications of such restrictions.” Her comment situates the findings within a broader political moment in which research on LGBTQ+ health and structural inequity faces growing constraints, even as the data suggest those very questions are central to ending the epidemic.

The practical implication, the authors write, is that supportive policies may need to be paired with concrete measures to help underserved communities obtain HIV prevention services. These could include targeted investments to expand resources in areas with healthcare shortages and the development of community-based prevention services in areas where stigma is high, though they caution that the most effective combination of approaches remains uncertain. The study, titled “State HIV Prevention Policy Environments and HIV Prevention Outcomes: Racial and Ethnic Differences in the United States,” was published on July 14, 2026, in AIDS and Behavior. In addition to Farkhad and Albarracín, it was co-authored by Feng Yi Chew and Angela Zhang of the University of Pennsylvania’s Annenberg School for Communication and Janet Lopez and Yubo Zhou of the university’s Department of Psychology. For a national HIV response that has staked much of its strategy on expanding PrEP and routine testing, the message of the study is sobering: the policy architecture that works on paper may not work equally for everyone it is meant to protect, and closing that gap will require looking beyond the statute books to the clinics, pharmacies, and communities where prevention either happens or does not.

Subject of Research: Racial and ethnic differences in how state HIV prevention policy environments relate to PrEP use and HIV testing in the United States

Article Title: State HIV prevention policies may benefit racial and ethnic groups unequally

Article References: State HIV prevention policies may benefit racial and ethnic groups unequally. (n.d.). Original publication

Image Credits: AI Generated

DOI: Not provided

Keywords: HIV prevention, PrEP, state policy, health disparities, LGBTQ+ health, HIV testing, racial disparities, AIDS and Behavior, policy research, public health, healthcare access, men who have sex with men