Why America’s HIV epidemic hasn’t ended is a question that continues to challenge public health officials, advocates, and communities across the United States. Despite the availability of highly effective prevention tools like pre-exposure prophylaxis (PrEP) and antiretroviral therapy that can render HIV non-transmissible, new infections persist at troubling levels, particularly among marginalized groups. Structural barriers, persistent stigma, and gaps in healthcare access have prevented the nation from capitalizing on biomedical advances that could, in theory, end domestic HIV transmission within a few years.
PrEP, when taken as prescribed, reduces the risk of acquiring HIV through sex by about 99 percent, according to the U.S. Centers for Disease Control and Prevention. For people living with HIV, consistent antiretroviral therapy can suppress the virus to undetectable levels, eliminating the risk of sexual transmission—a concept widely recognized as Undetectable = Untransmittable, or U=U. These tools represent some of the most successful public health interventions of the modern era. Yet, as of 2023, only about a third of the estimated 1.2 million Americans who could benefit from PrEP were using it, according to data from AIDSVu, an Emory University-led HIV surveillance project.
The disparity in PrEP uptake is starkly divided along racial, geographic, and gender lines. Black Americans account for approximately 40 percent of new HIV diagnoses but represent just 16 percent of PrEP users, while Latino individuals face rising infection rates—particularly among gay and bisexual men—yet remain underrepresented in PrEP programs. In Washington, D.C., where HIV prevalence reaches nearly one in 50 residents, infections are concentrated in predominantly Black neighborhoods, reflecting long-standing inequities in healthcare access and investment. Similar patterns emerge in the Southern United States, where states like Louisiana, Georgia, and Mississippi report some of the highest rates of new diagnoses in the country.
One of the most significant barriers to PrEP access is lack of awareness. Surveys indicate that roughly 60 percent of Americans have never heard of PrEP, according to a 2022 study published in the journal AIDS and Behavior. Even among those who are aware and seek the medication, navigating the healthcare system can be daunting. A 2022 Sermo survey found that less than half of primary care physicians feel knowledgeable enough to prescribe PrEP, contributing to delays and denials in care. Patients often report having to educate their providers about the medication, repeating lab tests, or facing judgment based on assumptions about their sexual behavior.
Stigma remains a powerful deterrent. Misconceptions that PrEP encourages promiscuity or is only for certain groups—such as white gay men—persist in both clinical and community settings. Women, particularly Black and Latina women, are frequently overlooked in PrEP outreach despite accounting for nearly one in five new HIV infections. Advocates note that historical messaging framed PrEP as a “party drug” during its early rollout, a narrative that has lingered and discouraged uptake among populations who do not witness themselves reflected in prevention campaigns.
Cost and insurance complexity also impede access. While most private insurance plans and Medicaid cover PrEP, out-of-pocket costs can exceed $2,000 per month for the uninsured. Although patient assistance programs exist—such as those offered by drug manufacturers Gilead and ViiV Healthcare, and state-level initiatives like the National Alliance of State and Territorial AIDS Directors (NASTAD) PrEP Assistance Program—enrollment processes can be burdensome. Ancillary costs for required HIV testing, kidney function monitoring, and quarterly clinician visits create logistical and financial hurdles, especially for those without flexible work schedules or reliable transportation.
Adherence challenges further limit PrEP’s impact. Studies present that between 37 and 62 percent of individuals discontinue oral PrEP within six months of starting, often citing pill fatigue, privacy concerns, or difficulty integrating daily medication into their routines. Long-acting injectable PrEP options—such as Apretude (cabotegravir), administered every two months, and the recently approved lenacapavir, which requires dosing only twice a year—offer promise in improving retention. Early data suggest that over 80 percent of users remain on injectable PrEP after six months, significantly higher than adherence rates for daily pills.
Though, access to injectables remains limited. These medications must be administered in clinical settings, and insurance coverage is not yet universal. MISTR, a telehealth platform founded in 2018 to expand PrEP access, has begun preparing brick-and-mortar clinics in LGBTQ+ neighborhoods across the country but has delayed opening pending broader insurer approval for injectable coverage. The company reports that nearly half of its users are people of color and more than three-quarters had never used PrEP before, highlighting telemedicine’s potential to reach underserved populations.
Community-based organizations continue to play a vital role in bridging gaps. Clinics like the Women’s Collective in Washington, D.C., provide PrEP alongside wraparound services such as food pantries, counseling, and social support groups, recognizing that housing instability, trauma, and substance use often intersect with HIV risk. Valerie Rochester, the Collective’s executive director, emphasizes that effective prevention must address the full context of a person’s life—not just their sexual health.
Federal policy shifts have further complicated efforts to expand PrEP access. In 2025, the Trump administration rescinded hundreds of millions of dollars in grants previously allocated to the Centers for Disease Control and Prevention for HIV prevention and outreach, including PrEP education and telehealth initiatives. The administration also disbanded the Presidential Advisory Council on HIV/AIDS (PACHA), a body that has advised the White House on HIV policy since 1995. While some states have maintained funding amid political pressure, advocates warn that weakened federal support threatens to reverse progress, particularly in regions already struggling with high transmission rates.
Despite these challenges, experts express cautious optimism. Vincent Guilamo-Ramos, director of the Institute for Policy Studies at the Johns Hopkins School of Nursing, notes that the biomedical tools to end HIV transmission in the U.S. Exist today. “We know how to eliminate HIV,” he said in a 2024 interview. “The question is whether we have the political will and systemic commitment to deploy them equitably.”
For individuals like Brenton Williams—a man whose fiancée is living with HIV and who has faced repeated obstacles in obtaining a PrEP prescription—the path forward remains frustratingly unclear. After months of navigating insurance requirements and provider uncertainty, Williams plans to seek care at a specialized clinic that affirms his needs without requiring him to justify his preventive care. His experience reflects a broader truth: ending the HIV epidemic in America will require not only better drugs, but a healthcare system that trusts patients, eliminates bias, and treats prevention as a routine, stigma-free component of sexual health.
The next major development to watch is the upcoming release of updated HIV surveillance data from the CDC, expected in mid-2025, which will provide clarity on whether national trends in new infections are improving, stagnating, or worsening. Until then, public health officials and advocates continue to urge expanded education, provider training, insurance reform, and community investment as essential steps toward closing the PrEP gap.
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