The study meticulously analyzed national pharmacy data, tracking oral PrEP prescriptions dispensed over a seven-year span. At the outset of this period, only 26 prescriptions per 100,000 young adults were recorded, but by the end of 2023, this rate had escalated dramatically to more than 208 per 100,000—representing a commitment from healthcare systems and patients alike to combat HIV transmission proactively. Nevertheless, while the rise in prescription rates is undeniably encouraging, the research also highlights critical challenges concerning adherence and sustained medication use within this vulnerable group.

An intriguing feature of the findings centers on the disparity in prescription rates between the younger subset (ages 18 to 21) and their slightly older counterparts (ages 22 to 25), with the former showing notably lower uptake. This phenomenon may be attributed to developmental, social, and healthcare access factors intrinsic to late adolescence and early adulthood. Compounding this issue is the observed decline in prescription refills’ duration—patients, on average, maintained their PrEP regimen for a shorter period by over two weeks compared to earlier years. Such inconsistencies in medication adherence raise concerns about the real-world effectiveness of PrEP outside of clinical trials.

The research team, led by Dr. Nina Hill, who balances roles as a general internist and pediatrician at the University of Michigan, underscores the complexity of navigating preventive care for young adults. This group often falls between pediatric and adult care models, leading to gaps in continuity and tailored health education. Furthermore, developmental psychology suggests that young adults may underestimate their susceptibility to sexually transmitted infections (STIs), including HIV, fostering less engagement with preventive healthcare services. Dr. Hill emphasizes the urgency of addressing these educational and systemic barriers to optimize the reach and impact of PrEP.

Critical to achieving consistent PrEP use is the sequence of medical interactions required for initiation and maintenance. Patients must first undergo HIV risk assessment, typically through provider consultations or validated online screening tools. Those deemed appropriate candidates then face an initial clinical evaluation involving tests not only for HIV but also other STIs, as well as assessments of renal function to ensure medication safety. Following prescription dispensing, rigorous follow-up every three to six months is essential, encompassing laboratory monitoring to detect any adverse effects and confirm ongoing HIV-negative status. Interruptions or irregularities in this continuum risk diminishing PrEP’s protective capacity.

The study also brings to light behavioral nuances around PrEP use, recognizing that some patients adopt event-driven or episodic dosing strategies. These regimens involve taking PrEP in anticipation of periods of sexual activity rather than daily use, demanding consistent access to medication and frequent healthcare contact. Ensuring that healthcare providers are equipped to counsel young adults on tailored PrEP strategies is paramount, especially when considering that irregular use may still confer significant but variable levels of protection depending on adherence fidelity.

Analysis of demographic data reveals further insights into geographic and gender-based patterns. Approximately one-third of the young adults receiving PrEP prescriptions resided in the southern United States—a region characterized by higher HIV incidence rates. Encouragingly, PrEP uptake in this area demonstrated the fastest growth during the study period, reflecting possibly intensified public health campaigns or shifts in regional healthcare infrastructure. While males composed the majority of PrEP users at 87%, the study acknowledges that women, particularly those with elevated HIV risk profiles, constitute an important but less represented group for PrEP intervention.

Medication formulation transitions over the study’s timeline play a relevant role. The initial PrEP drug, Truvada, introduced in 2012, became widely accessible as a generic in 2020, markedly reducing cost barriers. Additionally, Descovy emerged as a second oral PrEP option in 2019, though Truvada and its generic equivalents accounted for more than 70% of prescriptions. The arrival of injectable PrEP in 2021 represented an innovative advance in HIV prophylaxis, offering an alternative to daily pills. However, due to low uptake among young adults during the study period, injectable formulations were excluded from the analysis, indicating ongoing challenges in adoption and dissemination of newer treatment modalities.

The study further classified prescription origins by provider type, illuminating patterns in healthcare delivery. Nurse practitioners wrote 39% of PrEP prescriptions, underscoring their central role in preventive medicine and expanding access. Family medicine and general practitioners contributed 22%, while internal medicine physicians and physician assistants accounted for 14% and 11%, respectively. Notably, although emergency medicine physicians historically initiated few PrEP prescriptions, their involvement increased tenfold from 2016 to 2023, suggesting that emergency settings may be emerging as crucial points for initiating HIV prevention efforts among youth who might not otherwise engage in primary care.

This epidemiological research intersects with policy domains, particularly U.S. recommendations and insurance coverage mechanisms. Since 2019, the U.S. Preventive Services Task Force (USPSTF) has endorsed PrEP for adolescents and adults at increased risk for HIV. Furthermore, under the Affordable Care Act, most insurance plans are mandated to cover PrEP and related HIV screenings without patient cost-sharing if USPSTF criteria are met. Despite these provisions, ongoing legal challenges, such as the recent Supreme Court case Braidwood v. Kennedy concerning preventive care coverage, threaten to disrupt these protections and potentially impede access to lifesaving medications for vulnerable populations.

Dr. Hill and her colleagues advocate for enhanced dialogue among young adults, their healthcare providers, and trusted adults to dismantle stigma and misinformation surrounding sexual health. Expanding awareness about the efficacy of PrEP and streamlining pathways to access could bridge existing gaps. The multifaceted nature of HIV prevention necessitates a comprehensive approach that couples biomedical interventions with psychosocial support and structural reforms to sustain progress against the epidemic among young Americans.

This study’s findings represent a pivotal moment in understanding and confronting HIV risk among youth, emphasizing that increased prescription rates alone do not equate to effective prevention. Consistency in medication use, equity in healthcare access, and addressing developmental and systemic challenges remain crucial. As HIV continues to present global public health challenges, advancing tailored strategies and policy frameworks for young adults is indispensable for the ultimate goal of ending new HIV transmissions.

Subject of Research: People

Article Title: National Trends in HIV Pre-Exposure Prophylaxis Dispensing to Young Adults, 2016–2023

News Publication Date: 9-May-2025

Web References:

• https://link.springer.com/article/10.1007/s11606-025-09574-8
• https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/prevention-of-human-immunodeficiency-virus-hiv-infection-pre-exposure-prophylaxis
• https://jamanetwork.com/journals/jama/fullarticle/2735342

References:
Hill N., Chua K.-P., He S. National Trends in HIV Pre-Exposure Prophylaxis Dispensing to Young Adults, 2016–2023. Journal of General Internal Medicine. DOI:10.1007/s11606-025-09574-8

Keywords:
Human immunodeficiency virus, Preventive medicine, Chemoprevention, HIV prevention, Young people, Adolescents, Adults, Antiretrovirals, Antivirals, Pharmaceuticals

The study dives deeply into the concept of structural stigma, a form of societal-level discrimination that manifests through entrenched policies, cultural norms, and institutional practices, often producing systemic inequities that disproportionately burden sexual and gender minority (SGM) populations. Unlike interpersonal stigma, which is expressed through personal acts of bias or prejudice, structural stigma is embedded in the very fabric of societal functioning, operating invisibly yet pervasively to restrict resources, opportunities, and protections for stigmatized groups. This macro-level phenomenon, the authors argue, helps explain persistent health disparities that cannot be solely attributed to individual choices or interpersonal discrimination.

Tobacco use, well-established as a leading cause of preventable morbidity and mortality, emerges in this context as more than a mere lifestyle factor. It is a behavioral response embedded within socioecological frameworks where stressors, coping mechanisms, and access to health-promoting resources intersect. For SGM young adults, who frequently navigate heightened levels of stress associated with stigma and discrimination, tobacco use may represent both a coping strategy and a marker of deeper health inequities. By scrutinizing how structural stigma directs these behaviors, the study sheds light on the mechanisms perpetuating tobacco-related health disparities among these vulnerable populations.

Methodologically, the researchers employed a robust multilevel analytical approach, integrating individual-level survey data with comprehensive indices of structural stigma across geographic regions in the United States. By cross-referencing reported tobacco use behaviors with measures such as discriminatory laws, social policies, and cultural attitudes toward sexual orientation and gender identity, the study disentangles the complex pathways linking structural stigma and health behaviors. The inclusion of intersectional identities within the analyses underscores how compounding social disadvantages can amplify risk factors, providing a nuanced portrait of health inequities.

One of the striking findings highlights that young adults identifying as lesbian, gay, bisexual, transgender, or queer demonstrate significantly higher prevalence rates of tobacco use in regions with elevated levels of structural stigma. This pattern suggests that beyond individual psychosocial factors, the broader sociopolitical environment exerts a formidable influence on health risk profiles. Policies that marginalize or exclude SGM individuals contribute to entrenched stress, social isolation, and reduced access to affirming healthcare, collectively fostering conditions conducive to tobacco use initiation and persistence.

Further examination reveals that structural stigma influences not only the likelihood of tobacco use but also access to cessation resources and support systems. In states where discriminatory policies prevail, tobacco control programs are often less inclusive or accessible for SGM populations, undermining their effectiveness. This finding signals an urgent need for public health interventions that account for structural determinants and prioritize inclusivity in program design and policy advocacy.

The implications extend beyond tobacco use, reflecting broader patterns of health inequities rooted in systemic discrimination. Structural stigma’s impact on mental health, substance use, and chronic disease risk factors has been documented, and this study reinforces the notion that addressing societal-level barriers is indispensable for meaningful progress in health equity. Moreover, the researchers’ work calls for heightened attention to legislative and policy reforms as critical components of comprehensive public health strategies targeting marginalized youth.

Importantly, the study also explores variations within the SGM community, discerning differences in tobacco use behaviors and responses to structural stigma based on specific sexual orientations and gender identities. This intragroup analysis unveils that transgender and nonbinary individuals may face unique vulnerabilities, often compounded by intersecting forms of marginalization such as race, socioeconomic status, and geographic location. These intersections necessitate tailored interventions that recognize the heterogeneity within SGM populations and the multifactorial nature of stigma.

The researchers advocate for integrating structural stigma metrics into public health surveillance systems and tobacco control programs, enabling more precise identification of high-risk environments and populations. By mapping the landscape of social inequities alongside health behaviors, policymakers and practitioners can better allocate resources and design targeted interventions that disrupt the pathways from stigma to poor health outcomes.

Contemporary tobacco control efforts have achieved significant successes in the general population; however, as this study demonstrates, these gains are often unevenly distributed. Structural stigma acts as an insidious barrier to equitable health improvements, underscoring the importance of sociopolitical context in shaping disease burden. The call to action emanating from this research is clear: dismantling structural stigma must be central to efforts aimed at reducing tobacco use disparities and advancing health equity for all young adults.

To achieve these goals, multidisciplinary collaborations between public health professionals, policymakers, legal advocates, and community stakeholders are essential. Advocacy for inclusive policies that protect sexual and gender minority rights, coupled with culturally competent health promotion programs, can foster environments that discourage tobacco use and support cessation. Furthermore, ongoing research must continue to unravel the causal pathways linking structural factors to health behaviors, informing adaptive and responsive interventions.

In sum, this landmark study by Figueroa and colleagues represents a vital contribution to our understanding of the systemic roots of tobacco-related health inequities. By spotlighting the insidious role of structural stigma and its differential impact within the diverse SGM community, the authors provide a roadmap for comprehensive strategies that transcend individual behavior change, addressing the foundational social determinants of health. Their work not only advances scientific knowledge but also galvanizes action toward a more just and healthy society where all young adults can thrive free from the burdens of discrimination and its health consequences.

The findings resonate beyond tobacco control, offering a paradigm for examining structural stigma’s impact across various health domains and populations. As structural determinants gain recognition as pivotal drivers of health disparities, integrating this perspective into public health research and practice will be paramount. This study exemplifies the critical blend of rigorous methodology, theoretical grounding, and social justice orientation necessary to tackle complex health inequities in the 21st century.

Ultimately, addressing structural stigma requires concerted societal transformation alongside targeted health interventions. Policies that affirm and protect sexual and gender minorities, public education campaigns challenging stigma, and resource allocation for inclusive support services collectively contribute to dismantling the systemic barriers illuminated by this research. Through such collective efforts, the aspiration for equitable tobacco control and health outcomes among all young adults in the United States can move closer to realization.

Subject of Research: The study investigates how structural stigma influences tobacco use behaviors among young adults in the United States, particularly focusing on differences by sexual orientation and gender identity.

Article Title: Examining pathways between structural stigma and tobacco use: a comparison among young adults living in the United States by sexual orientation and gender identity.

Article References:
Figueroa, W., Sridhar, S., Jankowski, E. et al. Examining pathways between structural stigma and tobacco use: a comparison among young adults living in the United States by sexual orientation and gender identity. Int J Equity Health 24, 128 (2025). https://doi.org/10.1186/s12939-025-02487-2

Image Credits: AI Generated