PrEP Deserts: Why HIV Prevention Still Misses Those at Risk

In "PrEP Deserts: Why HIV Prevention Still Misses Those at Risk," our experts turn to the forces behind PrEP underuse, from how people perceive their own risk to how far they must travel for care.

Dr. Cocohoba introduces the concept of PrEP deserts and asks what drives underuse in Dr. Urbina's community. He calls it the million-dollar question. Gay men were the earliest adopters of PrEP, shaped by the history of the epidemic, but uptake has not spread to other groups. Dr. Urbina describes a disconnect between a person's actual risk and the risk they perceive. He argues that acquisition often reflects zip code and sexual network density rather than number of partners. For a young Black gay man in Harlem, a single encounter carries higher risk. He adds that early messaging tied PrEP to sexual pleasure and protection, which may not resonate with women. Even women with a recent STI frequently decline PrEP when it is offered.

Dr. Cocohoba reflects that the reasons are layered. Some people believe infection simply will not happen to them, while others face stigma, since accepting PrEP can feel like admitting risk. Dr. Urbina notes that oral PrEP remains closely associated with gay men. He hopes long-acting injectables, which resemble long-acting contraception, can link HIV prevention with reproductive health for cisgender women. Dr. Cocohoba credits the advocacy of men who have sex with men for today's range of options and calls for more inclusive messaging. Dr. Urbina adds that PrEP need not be lifelong, since people move through seasons of risk as relationships change.

Returning to PrEP deserts, Dr. Cocohoba defines them as places where a person in need lacks access to a prescriber. Access may be measured by census tract, zip code, or drive time. If a visit takes more than an hour to reach, patients simply will not go. Dr. Urbina proposes asynchronous PrEP with home specimen collection and mailed medication. Both faculty endorse telePrEP and local pharmacies as ways to bridge geographic barriers.

Up next, in "Building Clinician Confidence to Prescribe HIV PrEP in Primary Care," Dr. Urbina and Dr. Cocohoba lay out what primary care clinicians need to prescribe PrEP comfortably, from sexual history skills to shared team workflows.