Examining PrEP Use among Medi-Cal Beneficiaries in California: Differences at the Intersection of Race/Ethnicity and Sex

This Brief provides an update to the Southern California HIV/AIDS Policy Research Center policy brief Examining Pre-Exposure Prophylaxis (PrEP) Uptake among Medi-Cal Beneficiaries in California.¹ It provides additional information related to PrEP utilization at the intersection of race/ethnicity and sex. These data show that the number of Medi-Cal beneficiaries receiving PrEP in California continued to grow from 2013 through 2017. Large differences across racial/ethnic and age groups persist.

The Pharmacy Benefits and Information Management Divisions of the California Department of Health Care Services (DHCS) provided data on the number of Medi-Cal beneficiaries from 2012 to 2017. We examined time trends in the number of unique beneficiaries receiving PrEP and in the proportional distribution of users. Medi-Cal coverage for PrEP began in 2012. It was in April, 2014, however that Medi-Cal removed its requirements that a Treatment Authorization Request be submitted in order to access the medication. Thus, we considered numbers from 2013 as the baseline when examining trends, but provide graphs from 2012-2017. Analyses are limited to full-scope, certified eligible, non-dual, HIV-negative, ages 16-64 inclusive, receiving a prescription for PrEP in California at any point in each calendar year.

Please note, unlike in the previous policy brief, these data are not expressed in terms of rates per million. Thus, while they document numerical increases, disproportionality cannot be captured fully without further data on all Medi-Cal beneficiaries. Assuming, however, that the demographic make-up of Medi-Cal beneficiaries has remained steady over time, these data offer some insight into trends in PrEP utilization over time.

Between 2013 and 2016, the numbers of both male and female Medi-Cal beneficiaries receiving PrEP increased exponentially (Table 1, Figure 1). Year-to-year rates of increase in PrEP users have ranged from 716% to 54%. Among males, rates of increase have decreased steadily over time since 2013. Despite a greater increase in female PrEP users relative to males from 2016 to 2017, increases have been smaller in females overall. Males account for the majority of Medi-Cal recipients using PrEP (90%) and 87.4% of new HIV cases in the state.²

Table 1: Numbers of both male and female Medi-Cal beneficiaries receiving PrEP, 2013 to 2017 (Figure 2).

Table 2. Numbers of Medi-Cal beneficiaries using PrEP and annual increases 2013-2017, by race/ethnicity.

Medi-Cal beneficiaries in all ethnic groups showed rapid increases in use of PrEP from 2013 to 2017 (Table 2, Figure 3). Initially, rates of increase in PrEP users were greatest among white beneficiaries. However, annual rates of increase were greater for other groups in later years. Nonetheless, whites continue to account for the greatest single share of PrEP users. As of 2017, whites represented 33% of PrEP users covered by Medi-Cal and 26% of new HIV cases in the state.² (Table 2, Figure 4).

Table 3. Numbers of male Medi-Cal beneficiaries using PrEP and annual increases 2013-2017.

Trends in PrEP use among males by race/ethnicity are generally similar to overall trends, as illustrated above (Table 3, Figure 5, Figure 6).

Increased use of PrEP has occurred among women across racial/ethnic groups (Table 4, Figure 7). Differences across ethnic groups are less pronounced for women than for men. Thus, shares of each ethnic group among female PrEP users remained relatively steady (Figure 8). Overall, Hispanic women showed the greatest annual rate of growth (except 2016-2017) and in 2017 accounted for 29% of female Medi-Cal beneficiaries on PrEP (Figure 8).

We note that across genders, the share of PrEP users who are Asians has steadily decreased.

Table 4. Numbers of Female Medi-Cal beneficiaries using PrEP and annual increases 2013-2017.

Since the 2014 authorization of PrEP for Medi-Cal, the 25-34 age group has made up the largest number of those receiving PrEP (Table 5) and the 55-64 age group, the smallest (Table 5, Figure 9). Thus, 42% of PrEP users were aged 25-34 and 7% were 55-64 (Figure 10) 2017. It is notable that PrEP use remains low among Medi-Cal beneficiaries aged 16-24. In California, this younger age group aged 15-24 represent 19.7% of new infections statewide,² yet accounts for only 16% of Medi-Cal beneficiaries on PrEP.

Table 5. Numbers of Medi-Cal beneficiaries using PrEP and annual increases 2013-2017, by age group.

While more and more beneficiaries are using PrEP, rates of increase are slowing. Differences between the sociodemographic distribution of PrEP users and that of new HIV cases in the state signal concerning inequities in the delivery of this prevention modality.

The number of Medi-Cal beneficiaries receiving PrEP in California continues to grow.

Data from 2012-2017 indicate that, among all Medi-Cal beneficiaries receiving PrEP, the proportion who are Hispanic has increased over time. Given that Hispanics are the largest ethnic group among new HIV diagnoses,³ continuing to increase PrEP use among this population is vital.

Despite seeing a numerical increase in the number of Black men and women Medi-Cal beneficiaries receiving PrEP, their proportion among all PreP recipients remains largely unchanged.

Given trends in new HIV diagnoses in California,² a continued focus targeting Medi-Cal beneficiaries aged 15-24 is not misplaced.

While there are some pronounced differences among men across ethnic groups, this difference is less pronounced among women. Across genders, the share of PrEP users who are Asian has steadily decreased.

While these data are limited, they illustrate that disparities in PrEP use are likely impacting specific subgroups, specifically at the intersection of race/ethnicity and sex.

1. Harawa N, McBride S, Leibowitz A, Pulsipher C, Holloway I. Examining PrEP uptake among Medi-Cal beneficiaries in California: differences by age, gender, race/ethnicity and geographic region. California HIV/AIDS Policy Research Centers website. http://www.chprc.org/wp-content/uploads/2018/02/PrEP_Brief_2.8.18.pdf. February 8, 2018. Accessed June 25, 2019.

2. California Department of Public Health, Office of AIDS. California HIV surveillance report – 2017. https://www.cdph.ca.gov/Programs/CID/DOA/CDPH%20Document%20Library/California%20HIV%20Surveillance%20Report%20-%202017.pdf. March 13, 2019. Accessed October 2, 2019.

3. California Department of Public Health, Office of AIDS. Epidemiology of HIV in California – 2017. https://www.cdph.ca.gov/Programs/CID/DOA/CDPH%20Document%20Library/2017_Epi_Report.pdf. Accessed September 20, 2019.