There is a pill — and now an injection — that prevents HIV infection with up to 99 percent effectiveness, yet the majority of Americans who need it have never taken it. Pre-exposure prophylaxis, known as PrEP, has been available in oral form since 2012, and roughly 1.1 million Americans are at substantial risk for HIV and should be offered the medication, according to the CDC. Despite this, uptake remains stubbornly low, particularly among Black and Latino communities, women, and people living in the South — the very populations bearing the brunt of new infections. About 31,800 people still acquire HIV every year in the United States, a number that PrEP could drastically reduce if it reached those who need it most.
The reasons behind the gap are tangled and stubborn: stigma, lack of awareness, insurance barriers, geographic disparities, and a healthcare system that too often fails to bring prevention tools to the people most at risk. And now, in early 2026, federal funding cuts are threatening to make the problem worse, even as breakthrough long-acting injectables promise to make PrEP easier than ever. For those concerned about brain health and aging — the core of what we cover here — the connection is not abstract. HIV remains a significant risk factor for neurocognitive decline, and preventing infection is one of the most consequential things the healthcare system can do for long-term brain health. This article examines what PrEP is, who is falling through the cracks, and why the barriers to access are proving so difficult to dismantle.
Table of Contents
- What Is the Pill That Prevents HIV, and Why Aren’t Enough At-Risk People Taking It?
- The Racial and Gender Disparities That Define the PrEP Gap
- How Stigma, Awareness, and Cost Block Access to Prevention
- Daily Pills Versus Long-Acting Injectables — What Are the Real Tradeoffs?
- Federal Funding Cuts and the Threat to PrEP Programs
- The Promise of Lenacapavir and Global Access
- What Comes Next for HIV Prevention — and Why It Matters for Brain Health
- Conclusion
- Frequently Asked Questions
What Is the Pill That Prevents HIV, and Why Aren’t Enough At-Risk People Taking It?
PrEP comes in two main forms today. The first is a daily oral pill — either Truvada or Descovy — taken by HIV-negative individuals to block the virus before it can establish infection. When taken consistently, these pills reduce the risk of sexually transmitted HIV by up to 99 percent. The second, newer category includes long-acting injectables: cabotegravir (brand name Apretude), administered every two months, and lenacapavir (brand name Sunleca), given every six months. The World Health Organization now recommends all three options as part of its HIV prevention toolkit. Yet globally, only about 200,000 people are prescribed PrEP, and 75 percent of them are in the United States.
Even within the U.S., long-acting injectable PrEP accounts for just 1 to 2 percent of total prescriptions, despite the obvious advantage of not requiring daily adherence. The gap between who could benefit and who actually receives PrEP is enormous, and it is not shrinking fast enough. Consider: two-thirds of people who could benefit from PrEP are African-American or Latino, yet they account for the smallest percentage of prescriptions. Women, particularly Black women and those in low-income communities, remain substantially underrepresented among PrEP users, even as men have seen meaningful increases in uptake. The medication exists. The science is settled. The problem is delivery.
The Racial and Gender Disparities That Define the PrEP Gap
The disparities in PrEP access are not subtle. According to data from AIDSinfo at the National Institutes of Health, the HIV prevention pill is not reaching most Americans who could benefit, especially people of color. Black and Latino communities carry a disproportionate burden of new HIV infections, and yet they are the least likely to be prescribed PrEP. This is not a matter of biology or personal choice — it reflects systemic failures in healthcare access, provider awareness, and trust. Women face a parallel exclusion. Research from the University of Miami’s school of public health has identified persistent gaps in PrEP uptake among women. While men who have sex with men have been the primary focus of PrEP outreach and research, women — especially Black women in the South and in low-income settings — have largely been left out.
Many clinicians do not discuss PrEP with female patients, either because they do not perceive them as being at risk or because screening protocols are not designed with women in mind. However, if a woman is in a relationship with a partner whose HIV status is unknown or positive, or if she lives in a community with high HIV prevalence, she may benefit from PrEP just as much as any other at-risk individual. The failure to recognize this has real consequences. The geographic dimension makes things worse. The lowest PrEP uptake and the highest rates of new HIV diagnoses converge in the U.S. South, according to data from AIDSVu. States with the fewest resources and the most restrictive Medicaid policies are also the ones where HIV is spreading fastest — and where PrEP is hardest to obtain.
How Stigma, Awareness, and Cost Block Access to Prevention
Stigma is perhaps the most corrosive barrier. Taking a pill to prevent HIV requires, first, acknowledging that you might be at risk — and in many communities, that acknowledgment carries heavy social weight. Cultural perceptions around HIV, sexuality, and drug use make some people reluctant to seek PrEP or even discuss it with a healthcare provider. The American Journal of Managed Care has documented how this stigma operates at multiple levels: individual, community, and institutional. A person might fear being seen picking up a PrEP prescription. A doctor might avoid the conversation to sidestep an uncomfortable topic. Then there is simple lack of awareness.
Many at-risk individuals do not know PrEP exists. And many clinicians — particularly those outside of infectious disease or sexual health specialties — do not prescribe it or even mention it during routine visits. This is a quiet failure of medical education and public health messaging. A person cannot ask for something they have never heard of. Cost remains a real obstacle, though the landscape is complicated. The Affordable Care Act requires most private insurers to cover PrEP without cost-sharing, and manufacturer assistance programs exist. But some health insurers refuse to reimburse long-acting injectable PrEP, which can cost significantly more than the daily pill. For uninsured or underinsured individuals, particularly in states that did not expand Medicaid, the financial burden can be enough to end the conversation before it starts.
Daily Pills Versus Long-Acting Injectables — What Are the Real Tradeoffs?
For someone considering PrEP, the choice between a daily pill and an injection comes down to adherence, side effects, cost, and availability. The daily pills — Truvada and Descovy — are well-established, widely available, and covered by most insurance plans. Their main drawback is the discipline required: missing doses reduces effectiveness, and real-world adherence is lower than what clinical trials achieve. Descovy has a slightly different side effect profile and is not approved for use in people assigned female at birth who have receptive vaginal sex, a limitation that Truvada does not share. The injectables change the equation.
Cabotegravir (Apretude) requires an injection every two months, while lenacapavir (Sunleca) needs only two injections per year. For people who struggle with daily pills — whether due to housing instability, privacy concerns, or simply the difficulty of maintaining a routine — injectables offer a genuine advantage. However, both come with a notable downside: pain at the injection site. The CLARITY trial, the first head-to-head comparison of cabotegravir and lenacapavir injections, found that roughly 80 percent of participants reported pain after both types. Notably, 69 percent found cabotegravir “very” or “totally” acceptable compared to just 48 percent for lenacapavir. Neither is painless, but for many people, a sore arm or hip every few months is a reasonable tradeoff for near-complete protection against HIV.
Federal Funding Cuts and the Threat to PrEP Programs
The situation was already difficult. Now it is getting worse. The CDC paused its PrEP coverage reporting in 2024 and has been unable to resume, largely due to a reduction in force that gutted the Division of HIV Prevention. Without reliable data, it becomes harder to target resources, measure progress, or hold anyone accountable for failures in access. In early 2026, federal funding reductions began threatening PrEP access programs directly. As reported by aidsmap, PrEP uptake was already low — and then came the cuts.
Programs that provided PrEP navigation, covered medication costs for the uninsured, and funded community-based outreach are losing resources at exactly the wrong moment. For the populations already least likely to receive PrEP — Black and Latino communities, women, people in the South — the withdrawal of federal support could widen the gap further. This is not a hypothetical concern. When a clinic loses its outreach coordinator, the patients who needed that coordinator the most are the ones who disappear from the system entirely. The implications for long-term health, including brain health, are significant. HIV-associated neurocognitive disorders affect a substantial number of people living with HIV, even those on effective antiretroviral therapy. Every new infection that could have been prevented by PrEP is a person who now faces not only a lifetime of treatment but an elevated risk of cognitive decline as they age.
The Promise of Lenacapavir and Global Access
Lenacapavir, approved by the FDA and now available in the U.S., may represent the most significant advance in HIV prevention in years. Gilead, its manufacturer, can produce up to 10 million doses by 2026 — enough for 2.5 million users. More strikingly, studies have shown that lenacapavir could be manufactured for as little as 25 dollars per person per year, making global scale-up feasible in a way that earlier PrEP options never were. PEPFAR and the Global Fund have announced plans to launch lenacapavir at 64 dollars per person per year for one million people starting in 2026.
If this rollout succeeds, it could transform HIV prevention in sub-Saharan Africa and other high-burden regions. But the U.S. faces its own access challenge: insurance coverage for the injectable is inconsistent, and the infrastructure needed to deliver injections — clinic visits, cold storage, trained staff — is not the same as handing someone a bottle of pills. A twice-yearly injection is meaningless if there is no clinic within a hundred miles that offers it.
What Comes Next for HIV Prevention — and Why It Matters for Brain Health
The tools to end the HIV epidemic exist. A daily pill that is 99 percent effective. Injectables that require a clinic visit only a few times a year. A manufacturing cost that could make prevention available to millions globally. What does not yet exist, at least not at sufficient scale, is the political will and the public health infrastructure to get these tools to the people who need them. The federal retreat from HIV prevention funding in 2026 is moving the U.S.
in the wrong direction at the worst possible time. For readers of this site, the connection between HIV prevention and brain health is direct and well-documented. HIV crosses the blood-brain barrier and can cause neuroinflammation, white matter damage, and cognitive impairment — even in people who achieve viral suppression with treatment. Preventing HIV infection is, in a very real sense, preventing a form of acquired brain injury. Every barrier to PrEP access is also a barrier to protecting the long-term cognitive health of people at risk. The conversation about PrEP belongs not only in sexual health clinics but in every discussion about preserving brain function across the lifespan.
Conclusion
PrEP is one of the most effective prevention tools in modern medicine, capable of reducing HIV transmission by up to 99 percent when used as directed. Yet the gap between who needs it and who receives it remains vast, driven by stigma, lack of awareness, cost barriers, geographic disparities, and now federal funding cuts. Racial and gender disparities are especially stark: the communities most affected by HIV are the least likely to be offered PrEP. Long-acting injectables like cabotegravir and lenacapavir are expanding options, but they bring their own challenges around cost, insurance coverage, and clinical infrastructure.
For anyone at risk — or anyone who cares about someone at risk — the first step is a conversation with a healthcare provider about PrEP. For the healthcare system and policymakers, the obligation is clearer and more urgent: fund prevention programs, eliminate insurance barriers to injectable PrEP, and address the systemic inequities that keep this proven medication from reaching the people who need it most. The science has done its part. The rest is a matter of will.
Frequently Asked Questions
What is PrEP, and how effective is it at preventing HIV?
PrEP stands for pre-exposure prophylaxis. It includes daily oral pills (Truvada and Descovy) and long-acting injectables (cabotegravir every two months, lenacapavir every six months). When taken as prescribed, oral PrEP reduces the risk of sexually transmitted HIV by up to 99 percent.
Who should consider taking PrEP?
The CDC estimates that approximately 1.1 million Americans are at substantial risk for HIV and should be offered PrEP. This includes people with HIV-positive partners, those who do not consistently use condoms, people who inject drugs, and anyone in a community with high HIV prevalence. PrEP is not only for men — women at risk benefit equally.
Why are Black and Latino communities underrepresented among PrEP users?
Two-thirds of people who could benefit from PrEP are African-American or Latino, yet they receive the smallest share of prescriptions. The reasons include systemic barriers to healthcare access, medical mistrust rooted in historical mistreatment, stigma around HIV and sexual health, and the concentration of new infections in Southern states with fewer resources.
Does insurance cover PrEP?
Under the Affordable Care Act, most private insurers are required to cover PrEP without cost-sharing. However, coverage for long-acting injectable PrEP is inconsistent, with some insurers refusing to reimburse these newer options. Uninsured individuals may face significant costs, though manufacturer assistance programs and some state programs can help.
What is the connection between HIV and brain health?
HIV can cross the blood-brain barrier and cause neuroinflammation, white matter damage, and cognitive impairment — a condition known as HIV-associated neurocognitive disorder. This can occur even in people who achieve viral suppression with antiretroviral therapy. Preventing HIV infection through PrEP is a meaningful step in protecting long-term brain health.
How do the two injectable PrEP options compare?
Cabotegravir (Apretude) is given every two months, and lenacapavir (Sunleca) every six months. In the CLARITY trial, about 80 percent of participants reported injection-site pain with both, but 69 percent found cabotegravir acceptable compared to 48 percent for lenacapavir. Lenacapavir’s advantage is less frequent dosing; cabotegravir’s is greater tolerability at the injection site.
