This story is part of “Uninsured in America,” a project led by Public Health Watch that focuses on life in America’s health coverage gap and the 10 states that haven’t expanded Medicaid under the Affordable Care Act.
Jermany Gray worked up the nerve to ask his doctor about preventive medication for human immunodeficiency virus, or HIV, at his last check-up before leaving Jackson to go to college.
He knew that for someone like him – a young, Black, gay man living in Mississippi – the odds of acquiring HIV were alarmingly high.
In 2016, when Gray was a sophomore in high school, Centers for Disease Control and Prevention researchers estimated that if current HIV rates persisted, one in two Black gay or bisexual men would be diagnosed with the virus in their lifetime.
As college approached, he wanted to take his health – and his future – into his own hands. He asked his doctor to prescribe him pre-exposure prophylaxis, or PrEP, a highly effective medication that people who are not living with HIV can take to protect themselves from the virus.
But she refused to write the prescription and instead recommended that he abstain from having sex.
The bravery and excitement Gray had built up dissipated. “I kind of went back into my shell,” he said.
Gray’s experience isn’t an anomaly. Thousands of Mississippians with risk factors for HIV don’t take PrEP due to insufficient provider education, lack of awareness, stigma, affordability and limited access to health care.
Closing the gap
PrEP, which was approved by the Food and Drug Administration in 2012, blocks HIV from replicating in the body and has a 99% efficacy rate for preventing transmission by sex and a 74% efficacy rate for people who inject drugs, according to the CDC.
Epidemiologists and public health experts agree that getting the medication into the hands of people who need it most is critical to curbing the domestic HIV epidemic, which drags on with over 35,000 new diagnoses each year – in spite of scientific advances in prevention and treatment.
Expanding access to PrEP is a national public health challenge. But Mississippi is the farthest behind the rest of the country in reaching people who could benefit from the medication.
“States that have made more progress in getting PrEP to the people who would benefit from it are the same states that have experienced greater declines in HIV diagnoses,” explains Patrick Sullivan, an epidemiologist at Emory University whose research focuses on HIV prevention.
His research indicates that gaps in PrEP coverage are the most pronounced in states that have not expanded Medicaid – the policy intervention experts widely agree would be the most impactful intervention to increase PrEP coverage.
Medicaid expansion would alleviate the cost concerns and barriers that prevent many low-income and uninsured people from accessing health care services, said Dr. Leandro Mena, a clinician-researcher with expertise in prevention of HIV who spent many years of his career in Mississippi and is currently a professor at Emory University.
For over a decade, Mississippi has opted not to expand Medicaid to make health insurance available to more low-income adults in Mississippi. Expansion would result in 200,000 uninsured Mississippians gaining coverage and more low-income people seeking preventive care, said Khayla Scott, program manager for Mississippi Health Advocacy Program.
States that have expanded Medicaid are evidence of its impact, said Sullivan. His research shows that the number of PrEP users is 25% higher in states with Medicaid expansion, and 99% higher in states with PrEP drug assistance programs, or state-run programs to pay for medication and associated costs of care.
“It suggests that there are policy options that improve access to PrEP and utilization of PrEP, and probably a lot of other preventive services,” Sullivan said.
For Gray, moving to Louisiana for college was a turning point in his journey to get on PrEP. There, he had a doctor that was willing to prescribe PrEP and instantly qualified for Medicaid coverage.
Jermany Gray, a PrEP user and advocate for better access and awareness of the medication, poses for a portrait at Smith Park in Jackson, Miss., Tuesday, March 25, 2025. Credit: Eric Shelton/Mississippi TodayGetting on PrEP in Louisiana was “really forgettable, because it was that easy,” he said.
Medicaid not only covered Gray’s medication, but also his quarterly labs and appointments, which can be expensive. Under federal law, Medicaid plans must cover preventive services like PrEP, clinic visits and lab tests with no cost sharing.
Gray was able to get coverage because Louisiana expanded Medicaid in 2016, and while the state’s PrEP uptake, too, has been slower than the rest of the country, its rate of PrEP users is double that of Mississippi. The state has seen a noticeable drop in new HIV diagnoses since 2014.
When Gray returned to Mississippi after graduating, he found that accessing PrEP was again difficult – even with private insurance. His current plan doesn’t cover the name-brand PrEP he was previously prescribed, and he now has copays for the medication and routine testing.
It is impossible to know how many HIV infections might have been prevented if PrEP was used more widely in Mississippi — or if the state had expanded Medicaid at any point since 2014, when it first became an option and two years after PrEP was approved for use. But Mississippi’s slower PrEP uptake compared to the rest of the country may have contributed to its modest decline in new HIV cases.
HIV rates have ticked downwards in the United States since the late 1990s. But cases remain especially high in the South, where half of all new HIV diagnoses occur each year, and where most states have not expanded Medicaid.Mississippi has remained in the top 10 states for HIV incidence for over a decade, and today about 10,000 Mississippians are living with HIV. The state’s new HIV diagnosis rates have fallen over the last two decades, but at a rate slower than the nation as a whole.
People living with HIV in Mississippi are the least likely in the country to receive timely care or achieve viral suppression, which can also contribute to higher transmission rates. Viral suppression means that the amount of the HIV virus in the body becomes undetectable, which keeps people healthy and prevents the transmission of HIV to others.
Just 53% of Mississippians are connected to specialized HIV care within one month of their diagnosis, compared to a national average of 82%.
“We have so much work to do,” said Kendra Johnson, the director of communicable diseases at the Mississippi State Department of Health, who took the position last fall.
‘The era of PrEP’
In 2011, June Gipson became the chief executive officer of My Brother’s Keeper, a HIV prevention and treatment nonprofit in Jackson. She could tell that the world of HIV advocacy was changing.
“I knew things were different, but I couldn’t quite put my finger on what was happening,” she said.
It wasn’t long before she pinpointed the shift: “the era of PrEP” had arrived.
The behavioral HIV prevention interventions My Brother’s Keeper had focused on – “condoms and comfort,” and “testing and hand-holding,” in Gipson’s words – were no longer the most effective methods for preventing HIV, leading the organization to launch Open Arms Healthcare Center, one of the state’s largest PrEP providers, in 2013.
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