Alex (name changed for privacy) was a college student when he presented to the Sexually Transmitted Diseases (STD) Clinic at our medical center a few miles away from his campus. He knew that as a sexually active, young gay man, he was at higher risk of acquiring human immunodeficiency virus (HIV) than his heterosexual peers. While he used condoms most of the time, when he heard people talk about “the little blue pill that prevents HIV,” he decided to seek out HIV pre-exposure prophylaxis (PrEP) to further lower his risk. He understood that being on PrEP involved regular HIV and bacterial STD testing, and he was concerned about privacy and potential stigma at his school-affiliated student health center. He did an internet search for STD clinics around the city and even considered going to the emergency room before scheduling his PrEP intake with our STD Clinic. During his visit, he told his provider about flu-like symptoms and a diffuse rash, a foreboding sign that he may have recently been infected with HIV.

Two weeks later, Alex was the first person on my schedule in HIV clinic; his HIV test had returned positive. I walked into the exam room to see him sitting nervously in his chair. He jumped up to greet me, thanking me for seeing him. Already, he knew my name and the names of everyone else on his team. He had researched HIV treatment options but he still had questions about what his life would look like with HIV. Was he going to die? Could he still drink at parties? And would his parents, who pay for his health insurance, find out about his diagnosis?

We talked about how antiretroviral therapy has rendered HIV a manageable chronic condition for those with access to treatment, and people with HIV live long, productive, and happy lives. However, HIV would increase his chances of future medical complications, and unlike most young men his age, he would need to take daily medications and see his providers frequently. In spite of decades of advocacy, people with HIV may also face stigma and discrimination.

Earlier access to PrEP would have prevented this for Alex and many other young men like him.

Although daily tenofovir disoproxil fumarate/emtricitabine for PrEP was FDA-approved in 2012 and has robust safety and efficacy data—reducing HIV incidence in men-who-have-sex-with-men (MSM) by more than 90% 1—fewer than 15% of people in the USA who are eligible for PrEP have been prescribed it thus far.2 Sixteen- to twenty-four-year-olds are the age group with the lowest rate of PrEP coverage (defined as number of PrEP prescriptions per estimated people with indications for PrEP).3 Significant racial, ethnic, and socioeconomic disparities in prescribing also persist.4

The need to expand PrEP access among young MSM is particularly urgent and demands new and innovative outreach strategies. In 2016, HIV incidence in the USA was higher in those aged 25–34 than in any other age group (33.6 per 100,000 population) and 68.2% of new infections were attributed to male-to-male sexual contact.5 Although many sexual and gender minority youth face socioeconomic and educational disparities, many MSM do have the opportunity to attend college before this critical high incidence period. In one study of college-age MSM, the majority found taking a daily pill for PrEP to be acceptable and 90% felt positively about the additional medical visits and tests required for PrEP.6 College student health services are an underutilized resource for expanding PrEP access in a population not well-engaged by traditional office-based HIV prevention services.

College is a time of exploration and new independence. College students frequently report casual sexual experiences and less than 50% report mostly or always using condoms for vaginal or anal sex.7 Many young people arrive at college having received inadequate sexual health education that excludes information about non-heterosexual sexuality. The average age of first anal sex for young MSM is 17.4 years, an age just before most students start college.8 College students are at risk of HIV given their inexperience, sexual behaviors and often lack of sexual education.

For many young people, college is also the first time they are accessing healthcare on their own—either because they are living away from home for the first time or because they are turning 18 and moving from pediatric to adult medicine. College student health centers fill a vital role in this transition period, often serving as students’ primary source of care and offering geographic convenience, office hours designed to accommodate student schedules, and providers skilled in the medical needs of young adults. As such, student health centers represent an important care setting for HIV prevention services like PrEP.

As a well-educated college student with high health literacy, Alex had more opportunities than many young MSM to access PrEP, yet he did not get the preventive care he needed. Alex’s college has a student health center, but he did not know if it offered PrEP and worried he might be expelled were he found to have HIV. Instead of walking across campus, he delayed, eventually traveling across the city to find a place that felt more welcoming. We do not know if Alex would have faced stigma or discrimination had he been treated at his school, but his fear is not unfounded. Colleges and universities vary in their inclusivity to gender and sexual minorities, and three institutions in Massachusetts are listed on the Campus Pride Shame List for openly discriminating against these youth.9 Certainly more could have been done to make Alex feel welcome and accepted in his school’s student health setting.

There is reason to feel encouraged. Multiple college student health centers have begun to develop PrEP programs, advertising their services to students and offering care navigation.10 However, the uptake of PrEP services by student health centers and their efficacy as a whole remains unknown. To our knowledge, the only available data on PrEP prescribing in student health services was a survey of a small national sample of these clinics showing that less than 50% of institutions offered PrEP.11 Increasing PrEP uptake among young people is an urgent clinical and research priority, and preventing HIV in college students offers both individual and public health benefits. Student health centers represent a potentially untapped resource.

Alex is doing well. He takes one pill a day and his viral load has been undetectable since shortly after starting treatment. Still, we missed an opportunity for HIV prevention. Alex’s story is a call to action for college and university health services to offer PrEP in a welcoming, accessible, and destigmatized way in order to prevent HIV in the next generation of students.