nPEP Is Not the End: Lessons From London on the Transition to Rapid PrEP

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Released: September 22, 2026

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Nonoccupational postexposure prophylaxis (nPEP) should be considered an important entry point into ongoing HIV prevention. It is a way to prevent unnecessary gaps in HIV prevention for those with ongoing risk. Here, I discuss how to make the transition sufficiently streamlined so that patients do not need to navigate a second, potentially separate pathway to access PrEP.

Gary Whitlock, MD, PhD

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Nonoccupational postexposure prophylaxis (nPEP) should be considered as an important entry point into ongoing HIV prevention. For those whose risk of HIV exposure is likely to continue beyond the 28-day nPEP course, the end of nPEP provides an opportunity to transition directly to pre-exposure prophylaxis (PrEP), rather than allowing a gap in protection. Current WHO and CDC guidance support this immediate transition from nPEP to PrEP following completion of the nPEP course when HIV infection has been excluded.

Evidence for an Opt-Out Pathway
Our experience at 56 Dean Street, the United Kingdom’s largest sexual health clinic located in Soho, London, highlights the importance of making this transition proactive rather than relying on individuals to re-present at clinic after completing nPEP. We introduced an opt-out PEP2PrEP pathway at our service in 2021, offering people the option to receive a 28-day PEP supply and immediately start oral PrEP. Our data, presented at CROI 2024, demonstrate the feasibility and acceptability of this pathway. Among the 288 people receiving nPEP following sexual exposure in 2 months, 212 (74%) subsequently started oral PrEP after completing their 28-day PEP course. Among these, 142 initiated PrEP immediately after nPEP and 41 initiated within 60 days of nPEP consultation.

These findings support making the transition from nPEP to PrEP an integral part of the initial nPEP consultation rather than waiting until the end of treatment. At nPEP initiation, healthcare professionals (HCPs) should ask whether HIV exposure is likely to be an isolated event or whether there is an ongoing risk. In fact, the role of the HCP is to offer PrEP to all patients with ongoing risk so that it is the individuals themselves who decide if they want to use PrEP and/or other HIV prevention strategies. Previous nPEP or PrEP use, number of partners, condom use, adherence, anticipated future sexual activity, and individual preferences can help determine whether ongoing PrEP is appropriate. For people with continuing risk, the PrEP discussion should occur at the first nPEP visit and a specific transition plan should be agreed upon, including appropriately excluding HIV infection at the point of PrEP initiation.

Basically, the practical principle is preventing an unnecessary gap in HIV prevention. The transition should be sufficiently streamlined so that the patient does not need to navigate a second, potentially separate pathway to access PrEP.

Individualization Facilitates Uptake
The choice of PrEP modality should then be individualized. Oral PrEP remains highly effective and is particularly attractive for people who prefer self-administered prevention, have intermittent periods of risk, or value starting and stopping oral PrEP. The nPEP consultation also provides an opportunity to identify barriers to adherence and discuss whether a long-acting option may be preferable. When barriers to oral PrEP adherence are identified at our service, our health adviser team have dedicated sessions to support these individuals.

Long-acting PrEP offers an alternative for people who find daily tablets difficult or prefer not to take medication around sexual activity: guidance varies globally. Long-acting cabotegravir and lenacapavir are 2 options that avoid daily pill-taking.

Whatever the choice of PrEP, the key is that the end of the course of nPEP should not be the end of prevention. Rather, the start of nPEP is also an opportunity to discuss ongoing PrEP, offering a chance for protection that extends beyond the end of nPEP.

Your Thoughts
What are some other ways you can prevent unnecessary gaps in HIV prevention after PEP, or after an initial consultation for PrEP? Leave a comment to join the discussion!

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