Abstract: INTRODUCTION: Uptake of HIV pre-exposure prophylaxis (PrEP) within the US Veterans Health Administration (VHA) remains modest, especially among younger women. Younger women face a disproportionately high risk of HIV infection due to biological, behavioral, and structural factors and experience the greatest barriers to PrEP access compared with older women. To examine gaps in PrEP delivery for this high-risk group, we conducted in-depth chart reviews of patients younger than 26 years identified as female at birth. METHODS: Among all VHA patients prescribed PrEP from 2012 to 2022, 24 were younger than 26 years. We reviewed the charts of all 24 of these patients. For each, we selected a matched comparison patient younger than 26 years, with a laboratory-confirmed gonorrhea or chlamydia diagnosis in the same year who had not been prescribed PrEP. Forty-eight charts (24 PrEP users, 24 non-PrEP users) were reviewed and analyzed using qualitative content analysis. RESULTS: Nearly half (46%) of PrEP users were identified as transgender during chart review. Many (46%) initiated PrEP discussions with their providers, and 75% received prescriptions from infectious disease clinics. The most common barrier observed was missed opportunities for providers to discuss PrEP-even after STI diagnoses. Compared with PrEP users, non-PrEP users were more likely to have documented substance use, housing instability, sleep disturbances, and post-traumatic stress disorder or anxiety. CONCLUSIONS: Our findings highlight the need for improved PrEP outreach, particularly for younger women and gender-diverse Veterans. Addressing missed opportunities, structural vulnerabilities, and provider engagement may enhance equitable access to PrEP within the VHA.