Content warning: This article mentions sexual assault and substance use.
During my time as a PrEP navigator, I received calls nearly every week from individuals who were frantic over having possibly been exposed to HIV. The scenario played out in many different ways but almost always included one common trait: None of the callers knew about non-occupational post-exposure prophylaxis (nPEP), simply called PEP, until they needed it urgently―when the clock was ticking.
PEP is typically discussed as part of a safety precaution for workers who might come in contact with sharps or blood in medical settings. Though PEP is an important component of HIV prevention, few people in the general population know what it is. Just as troubling, many of my former clients reported that frontline staff―such as receptionists or medical assistants―at emergency rooms or urgent care centers were rarely familiar with the drug. This was the case whether my former clients shared with those workers that they might have been exposed to HIV or inquired about PEP specifically.
This issue goes beyond mere anecdotes. In 2020, AIDS and Behavior published a study on the awareness and prescribing history of PEP among U.S. health care providers. Using data collected between July 2014 and May 2015, the study found that despite PEP being clinically recommended since 2005, 12.5% of 480 medical providers surveyed in 10 high-HIV-prevalence zip codes had no prior knowledge of it―while 43.5% had knowledge about PEP but no experience prescribing it.
The Ending the HIV Epidemic initiative correctly recognizes biomedical strategies such as pre-exposure prophylaxis (PrEP) and U=U messaging (undetectable equals untransmittable) as key strategies for drastically reducing new HIV acquisitions. With respect for the fact that HIV prevention needs to address all sorts of possibilities, it is time to increase the general population’s information about PEP as well.
What Is PEP?
Post-exposure prophylaxis, or PEP, is the use of antiretroviral therapy (ART) to prevent HIV acquisition after a possible exposure through sex, injection drug use, or needle stick. ART is the category of drugs used for HIV prevention (PrEP) and treatment to interrupt HIV’s life cycle. Being exposed to HIV does not mean that transmission will occur, but the general understanding when it comes to potential seroconversion is that it is better to be safe than sorry and to exhaust all possible preventative options.
With that in mind, it is important to note that PEP is not guaranteed to work in every circumstance. But if it is to be effective, it must be started within 72 hours of one’s exposure to HIV, and its regimen must be taken daily until it is completed (28 days).
As the New York State Department of Health's (NYSDOH) PEP to Prevent HIV Infection guidelines note, it is important to start treatment for suspected exposure to HIV when one is not using PrEP or barrier methods (or if one has experienced a breach in one’s barrier method) as soon as possible. PEP begins to lose its effectiveness incrementally after two hours and has been found to be ineffective after 72 hours. For this reason, the NYSDOH’s guideline states, “An intentional decision to wait until the 72-hour mark to initiate PEP could place an exposed individual at increased risk of seroconversion [emphasis in original].”
According to the AIDS Education and Training Center’s (AETC) guide for providers, a three-drug regimen that mirrors HIV treatment is recommended for PEP because of its concentrated strength and the potential consequences of being exposed to HIV without protection. With that in mind, two-drug, single-pill regimens―such as TDF/FTC (brand name Truvada) or TAF/FTC (brand name Descovy)―are not recommended by themselves for treatment, although these drugs may be prescribed in combination with others.
People looking for information about PEP at the Centers for Disease Control and Prevention (CDC) will find that its only guidelines were published in 2005 and 2016 (the update includes pediatric dosing information). In fact, the CDC links to the AETC’s guide for current information.
PEP is usually covered by the same copay and medication assistance programs that assist with PrEP coverage and can be accessed at low- or no-cost sexual health clinics, urgent cares, or federally qualified health centers (FQHC). As with PrEP and HIV treatment, a series of labs and consultation with a medical provider are required to receive a PEP prescription, though one does not have to wait for the labs to return before prescribing it to a patient. A PrEP navigator or patient advocate at a hospital or clinic can help someone who may have been exposed to HIV to access the necessary resources to begin treatment.
Why Don’t We Talk About PEP?
Ending the HIV epidemic means exhausting all biomedical HIV prevention tools, yet still there are no major campaigns to bring awareness to PEP. Additionally, many sexual health clinics either do not list PEP as a prevention service or said references are buried under information about condoms, testing, and PrEP.
HIV.gov and CDC.gov’s prevention pages list PEP in a drop-down menu by its name, not an easily understood phrase, meaning one would have to know what PEP is to uncover that information. When dealing with a 72-hour window period, as well as the potential panic that can accompany awareness of exposure, finding information that one barely understands on inefficiently constructed websites can be all but impossible.
People already deal with numerous barriers to information about sexual and reproductive health due to puritanical politics around sex education. So why are our sexual health clinics and public health institutions continuing to stand in the way by not making HIV prevention information easily accessible―especially in emergency situations?
A prevention tool that has been able to prevent HIV for almost two decades warrants the same level of marketing, education, and outreach as condoms or breast cancer awareness. That means making posters and brochures available and visible in sexual health clinics, while also equipping outreach workers with information about PEP.
An even better step toward boosting awareness of and access to PEP would involve tasking sexual health websites with assessing how easy it is for someone with no knowledge of PEP to learn about it on their platforms―and launching a full revamp based on the results. To that end, PEP could be prominently featured on prevention pages with language such as, “Have you had a recent exposure to HIV? Try PEP,” which could help alert those with no knowledge of the drug but who might have an urgent need to find it.
PEP Is a Gateway to Engaging in Other Services
During my time as a PrEP navigator, I frequently engaged with people who feared that they'd been exposed to HIV. In each case, their first step was to ask for a rapid test. After explaining that HIV cannot be detected within 72 hours of exposure, we would move on to educate the person about routine testing for HIV and other sexually transmitted infections.
Often, after learning about the possibility of PEP, it would emerge that our new clients were also unaware of PrEP or had previously thought they wouldn’t need it. Almost all our PEP clients would begin PrEP upon completion of their regimen. Connecting people to PEP allows PrEP navigators and providers to establish one-on-one conversations about safer sex options―whether it be condoms, PrEP, sexual health screenings or a combination of the options―with individuals we might otherwise have never seen.
Sometimes, the need for PEP came not from a broken condom or the consensual decision to forgo using one. As a PrEP navigator, I was frequently the first person a client confided in after a sexual assault, being stealthed by a partner, or an episode of substance use that led to impaired judgment around using harm reduction.
Though the fear of being exposed to HIV can be upsetting unto itself, when paired with sexual violation or shame, one can experience a level of trauma that is impossible to sufficiently address during a sexual health consultation―especially when the focus is on accessing PEP as soon as possible. However, that conversation can open the door to providing resources to a client who might also need mental health services, substance-use counseling, or peer-support groups.
PEP is an HIV prevention resource that must be scaled up drastically to bring awareness to both clients and medical staff. But it can be more than a regimen for HIV prevention. PEP could be another holistic intervention that introduces people to a range of sexual and mental health resources and information. If we as medical professionals and navigators don’t do our part to educate everyone who can benefit from PEP―meaning, anyone who might have condomless sex without first being on PrEP―and reduce barriers to access, we are committing a grave disservice against the communities that continue to be disproportionately affected by HIV.