Pre-exposure prophylaxis (PrEP) works well to prevent HIV, but has not gained widespread adoption among family medicine clinicians. We sought to report the extent of PrEP prescribing among residency programs and understand the acceptance of and barriers to it being taught and prescribed. Data were collected as part of the 2017 CERA Family Medicine Program Director (PD) Survey. PDs provided information their program’s PrEP use, instruction, perceived provider competency. We modeled most PrEP-eligible patients being treated by grouping the treatment responses of “0-25%," with“26-50%" and “51-75%" with “>75%." Graduating resident PrEP competency was modeled by grouping responses “none" with “basic" and “independent" with “advanced." Significant training was used to categorize respondents indicating “significant formal training" compared to those indicating lesser categories. Rural communities were identified using the reported residency service population as < 30,000 compared to larger service populations. Logistic regression was used to generate odds ratios for the modeled outcome. Chi-square testing was done for the rural-urban comparison with training as rural status perfectly predicted not having significant training and could not be modeled with regression. Stata 14 was used for all analyses. A total of 298 of 522 (57%) of program directors who could be identified responded to the survey, with a total of 276 program directors (53%) responding to the PrEP questions. No residency programs in a rural setting (population of <30K) reported having significant training in PrEP therapy compared to 17% or larger population-based residencies (P = 0.021). In comparing programs with significant formal PrEP training to those with less, the odds of most PrEP-eligible patients being treated was 7.3 times greater (P < 0.001), and the odds of a minimum of independency in PrEP competency for graduating residents was 18.3 times greater (p < 0.001).Conclusions: Some residency programs in rural settings lacked significant training in PrEP therapy. This lack of training in those rural areas will likely result in residents of these programs having less comfort with recommending and prescribing PrEP therapy for patients while in residency, which can lead to missed opportunities for HIV prevention in high risk patients.