Immediate PrEP When Accessing PEP: A Service Evaluation

Beatrice Cockbain; Gary Whitlock


HIV Medicine. 2022;23(10):1108-1112. 

In This Article

Abstract and Introduction


Objectives: In January 2021, 56 Dean Street, a London sexual health clinic, changed clinic policy so that all those attending for post-exposure prophylaxis (PEP) were offered quick-start opt-out pre-exposure prophylaxis (PrEP) following completion of the 28-day PEP course. We assessed the uptake of this quick-start PrEP in service users attending for PEP.

Methods: We undertook a case note review of those who received PEP during the 2-week period from 17 February to 1 March 2021, assessing the data and comparing them to those from the same period in 2020 (15 February–28 February 2020) before quick-start opt-out PrEP was introduced.

Results: The number of service users receiving PEP was 82 in 2020 and 42 in 2021, of which an unmet PrEP need was demonstrated in 81.7% (67/82) in 2020 and 78.6% (33/42) in 2021 (p = 0.8106). Of those with an unmet need, a higher proportion (97.0% [32/33]) were offered PrEP in 2021 following the introduction of opt-out PrEP compared with the 85.1% (57/67) in 2020 (p = 0.0953). Of those eligible for PrEP who were offered it during their PEP consultation, 53.1% (17/32) in 2021 were dispensed PrEP compared with 17.5% (10/57) in 2020 (p = 0.0007).

Conclusion: Since the introduction of quick-start opt-out PrEP, uptake in eligible candidates increased from 17.5% to 53.1%. This suggests that this strategy was acceptable to service users.


Attendances for HIV post-exposure prophylaxis (PEP) are not only an opportunity to prevent immediate acquisition of HIV but also a chance to discuss future risk and initiate appropriate ongoing HIV-prevention strategies. From August 2020, following the UK national health service (NHS) roll-out in England,[1] HIV pre-exposure prophylaxis (PrEP) has been available free of charge at 56 Dean Street (56DS), a London sexual health clinic, as generic co-formulated tenofovir disoproxil fumarate 245 mg/emtricitabine 200 mg tablets.

PrEP has been available online, privately, or within trials since 2015, and PEP demand has fallen significantly since then.[2] Despite the availability of PrEP free of charge in England, there remains an unmet need for PrEP (defined as those fulfilling the criteria for PrEP prescriptions yet without access to the medication), particularly among marginalised groups.[3] PEP attendances in sexual health services represent one point of access to other HIV-prevention programmes such as PrEP and as such are critically important for not only the immediate but also the long-term elimination of HIV transmission risk. The immediate initiation of PrEP after PEP (so-called PEP2PrEP) has significantly reduced new HIV acquisitions[4] given the increased risk of HIV acquisition in men who have sex with men who present for PEP.[3–7] Immediate PrEP is now recommended by national guidance in the United States[8] and the UK.[9]

At 56DS, all service users starting PEP or PrEP undergo the following HIV tests: a third-generation finger-prick point-of-care test and a fourth-generation serology test, with repeat serological testing 6 weeks later to cover any HIV risk during the window period of the baseline HIV tests.

After reviewing the case notes of people newly diagnosed with HIV at 56DS in 2020, we found that, of those who had attended 56DS in the previous 12 months, 85% demonstrated a risk factor for HIV acquisition.[10] Of these, there was a large gap between PrEP awareness (86%) and PrEP uptake (34%).[10] To increase appropriate PrEP use, 56DS clinic policy changed in January 2021 so that all those attending for PEP were offered quick-start opt-out PrEP with a 1-month supply to initiate after PEP completion and dispensed either on the same day as attendance or prior to the end of the 28-day PEP course according to service users' preference. By discussing PrEP in all PEP consultations, this not only provided an opportunity for service users to access quick-start PrEP but for those with a history of PrEP use to confirm its correct dosing and, if indicated, suggest changes from intermittent to daily use.

In this service evaluation, we assessed the impact of offering quick-start PrEP in PEP consultations on service users' uptake of PrEP.