The effect of state-level policy climate on HIV pre-exposure prophylaxis use and the role of internalized stigma

Background: Anti-lesbian, gay, bisexual, transgender, and/or queer (LGBTQ+) legislation has dramatically increased in the United States. These laws limit the rights of sexual and gender minoritized (SGM) youth, but their health effects remain understudied. We estimated how a hypothetical intervention setting states to have more equitable LGBTQ+-related policies would affect individual-level pre-exposure prophylaxis (PrEP) use among SGM youth and young adults, and whether internalized stigma mediates this effect. Methods: Keeping it LITE-1 was a national cohort (2017-2022) of 3330 SGM youth and young adults (ages 13-34) at an increased HIV risk. Semiannual surveys collected geolocation, internalized HIV and LGBTQ+ stigma (high/low), and self-reported PrEP use (yes/no). Geolocation was linked with state-level LGBTQ+ policy data from the Movement Advancement Project (MAP). LGBTQ+ laws were characterized as less or more discriminatory based on MAP score distributions. We estimated the average treatment effect of state-level LGBTQ+ policy environment on PrEP use, and the controlled direct effect if all participants had lower internalized stigma. Results: If all participants lived in states with less discriminatory anti-LGBTQ+ policies, we would expect PrEP use to increase by 14%, compared to if all lived in states with more discriminatory policies (0.14; 95% CI: 0.09-0.18). This increase was largest among Black participants (0.23; 0.05-0.38). Reducing internalized stigma did not change this effect (13% vs. 14%). Conclusion: Creating more equitable state-level LGBTQ+ policy climates could considerably increase national PrEP use, and thereby decrease HIV incidence. Repealing harmful anti-LGBTQ+ laws and implementing protective policies could substantially reduce population-level HIV transmission.