Kellen A. Kane, Ph.D., MPA

The Changing Landscape of PrEP Deserts in the United States

Kellen A. Kane

Pre-exposure prophylaxis (PrEP) is a critical intervention that greatly reduces the risk of HIV transmission, yet limited access to prescribing providers continues to constrain uptake in the United States. This study examines how geographic access to PrEP providers changed between 2020 and 2023 and identifies areas with limited access, referred to as PrEP deserts. Using the Integrated two-step floating catchment area method, this study finds that despite widespread gains in PrEP access, five states experienced increases in the total population living in PrEP deserts. Additionally, more than 5 million residents in states designated as priority jurisdictions under the Ending the HIV epidemic initiative gained geographic access to PrEP providers between 2020 and 2023. However, improvements were uneven: in some states, communities of colour experienced declining access and remain disproportionately represented in PrEP deserts. These findings highlight persistent geographic and demographic disparities in HIV prevention infrastructure despite recent federal efforts to expand PrEP availability.

Implementing Title X: Policy Design, Administration, and Geographic Access to Care

Tracee M. Saunders, Kellen A. Kane, and Candis Watts Smith

Title X of the Public Health Service Act is a critical federal program—the only one dedicated exclusively to providing affordable, confidential, evidence-based reproductive health care to low-income populations, yet its capacity to fulfill this mandate depends on political, administrative, and fiscal decisions made across multiple levels of governance—from Congress and federal regulators to state and regional grantees and their sub-grantee clinic networks. This study assesses geographic access to Title X-funded clinics across all 50 states and the District of Columbia in 2024, a period with significant program and regulatory disruption. Using the Integrated Two-Step Floating Catchment Area (I2SFCA) method—which employs road-network-based drive time thresholds calibrated to urban–rural context—applied to 2024 clinic locations and census-tract-level demographic data, we identify a confluence of spatial and nonspatial barriers to Title X. Findings reveal widespread and substantial gaps in geographic access, a challenge faced by people across all racial groups, rural and urban residents, and individuals with low incomes. These findings offer a precise geographic account of where Title X's reach falls shortest—documenting the ramifications of policy retrenchment and establishing a baseline against which future policy changes can be measured.

Contraception Deserts: The Effects of Title X Rule Changes on Access to Reproductive Health Care Resources

Candis Watts Smith, Rebecca J. Kreitzer, Kellen A. Kane, and Tracee M. Saunders

Historically, access to contraception has been supported in a bipartisan way, best exemplified by consistent congressional funding of Title X—the only federal program specifically focused on providing affordable reproductive health care to American residents. However, in an era of partisan polarization, Title X has become a political and symbolic pawn, in part because of its connection to family planning organizations like Planned Parenthood. The conflicts around Title X highlight the effects of intertwining abortion politics and contraception policy, particularly as they relate to reproductive justice and gendered policy making. Family planning organizations like Planned Parenthood have responded to these battles by bowing out of the Title X network. To what extent have contraception deserts—places characterized by inequitable access to Title X—developed or expanded in response to policy changes related to contraception and reproductive health? What is the demographic makeup of these spaces of inequality? We leverage data from the Office of Population Affairs and the U.S. Census Bureau and use the integrated two-step floating catchment area method to illustrate the effects of a major change in the Title X network in 10 states. Our results reveal the widespread human ramifications of increasing constraints on family planning organizations as a result of quiet but insidious federal bureaucratic rule changes.

Affordable but Inaccessible? Contraception Deserts in the US States

Rebecca J. Kreitzer, Candis Watts Smith, Kellen A. Kane, and Tracee M. Saunders

This article focuses on whether, and the extent to which, the resources made available by Title X—the only federal policy aimed specifically at reproductive health care—are equitably accessible. Here, equitable means that barriers to accessing services are lowest for those people who need them most. The authors use geographic information systems (GIS) and statistical/spatial analysis (specifically the integrated two-step floating catchment area [I2SFCA] method) to study the spatial and nonspatial accessibility of Title X clinics in 2018. The authors find that contraception deserts vary across the states, with between 17% and 53% of the state population living in a desert. Furthermore, they find that low-income people and people of color are more likely to live in certain types of contraception deserts. The analyses reveal not only a wide range of sizes and shapes of contraception deserts across the US states but also a range of severity of inequity.

The journal's second most-read article of 2021. Covered by The Economist, Forbes, and PBS and cited in a proposed rule by the U.S. Department of the Treasury.