- Post-exposure prophlyaxis (PEP) can prevent HIV after an exposure, if taken as soon as possible
- To minimize delays in starting, “PEP in Pocket” offers this medication to patients in advance
- Toronto researchers found that PEP in Pocket allowed participants to avoid urgent care
New Canadian data show that dispensing post-exposure prophylaxis (PEP) before the need arises provides people with the option of strong protection against HIV while allowing for choice and flexibility. PEP involves the use of a combination of anti-HIV drugs that are taken every day for 28 consecutive days. Usually PEP is accessed at the emergency room of a hospital or urgent care clinics. For PEP to be effective, it has to be initiated within 72 hours of potential exposure to HIV.
Enter PEP in Pocket, or PiP, for short. PiP consists of giving a month’s worth of PEP to people to keep at home until they have a potential exposure to HIV, at which time they can immediately start the medication without needing to seek urgent care.
As of July 2024, PiP is now included in the World Health Organization (WHO) HIV prevention guidelines as an option. The guidelines suggest that it is better to prescribe and dispense a one-month course of PEP rather than shorter-term or partial prescriptions. This approach means fewer clinic visits for PEP and that patients can initiate PEP as soon as it is needed.
An update on how PiP works
University of Toronto infectious disease specialist Isaac Bogoch, MD, who conceptualized PiP around a decade ago, recently presented updated data on its implementation at the International AIDS Society’s HIV For Prevention Conference. In his most recent study, 128 people, mostly male, were given PiP in two large HIV prevention clinics in Toronto between 2016 and 2024. About one-third of these patients decided to self-initiate the PEP they had received, with around half of that group doing so more than once.
No one who initiated PiP became HIV positive during the study. Over time, researchers found that some participants moved from using PiP to PrEP (pre-exposure prophylaxis) and vice versa, depending on their needs.
Importantly, the data shows that none of the patients went to an emergency department or urgent care clinic for HIV prevention reasons. Instead, the majority followed up at their leisure at their usual clinic. Almost all of those on PiP completed testing for HIV and other sexually transmitted infections (STIs) within the first six months of initiating PiP.
In related research, data submitted for publication from University of Ottawa researcher Mia Sapin shows that PiP is about 43% less costly than PrEP.
Ideal for dynamic exposure
According to Dr. Bogoch, PiP specifically caters to people who may have up to four possible HIV exposures per year. This means that they are not high risk enough to ideally be on PrEP but they still face some risk. This might be because they use condoms most but not all the time, or they share equipment for using drugs but only rarely. People in the study who were at intermittent risk for HIV included sex workers, people who inject drugs, and some gay, bisexual and other men who have sex with men (gbMSM).
Dr. Bogoch suggested that PiP is ideal for people whose risk levels are mid-range and dynamic. In other words, PiP is an HIV prevention option that can meet the needs of some people at risk for HIV.
Dr. Bogoch’s findings show that PiP works at preventing HIV and that it is flexible for people who have intermittent risk. He likens it to one dish on the “buffet” of prevention methods.
Out of the ER and into patients’ hands
Patients taking PiP into their own hands and using it when needed means that they do not fill up emergency care units. This lessens the administrative burden for clinic staff and reduces possible stress on patients seeking PEP, particularly if the exposure was traumatic. Plus, with PiP, the care can be done with a known and trusted healthcare provider.
This also means that there is a level of autonomy for patients to easily and quickly access PEP effectively, side-stepping possible access issues in the future. Beyond this, the cost-effectiveness makes it ideal for certain patients.
At the presentation, Dr. Bogoch emphasized that this method of dispensing PEP respects patients’ freedom. “We just give it to people ahead of time,” he says. “Let’s treat adults like adults and let them self-initiate.”
For the future
According to Dr. Bogoch, researchers are currently doing larger prospective studies on PiP and a lot of implementation work. The recent WHO guideline inclusion means that implementation internationally is likely to increase. He stated that local and national implementation of PiP is growing.
While much of his research team’s work is among gbMSM, Dr. Bogoch states that he is aware that women who are at risk for HIV are often severely neglected. He is working closely with women’s groups to improve this.
Ultimately, PiP continues to offer a unique approach to HIV prevention and post-exposure prophylaxis that is particularly useful for certain patient groups. It emphasizes decreased costs and increased agency, while still providing effective HIV prevention care.
—Elna Schütz
Resources
Study explores self-initiated HIV post-exposure prophylaxis – CATIE News
A novel HIV prevention approach called PiP in cases with infrequent exposure to HIV – CATIE News
Guidelines for HIV post-exposure prophylaxis – World Health Organization
REFERENCES
- Fisher K, Billick M, Bogoch I. HIV PEP-in-Pocket (“PIP”) facilitates the de-medicalization of HIV prevention. HIVR4P 2024, the 5th HIV Research for Prevention Conference, 6-10 October 2024, Lima, Peru. Abstract OA2007LB.
- Billick MJ, Fisher KN, Myers S, et al. Brief Report: Outcomes of individuals using HIV postexposure prophylaxis-in-pocket (“PIP”) for low-frequency, high-risk exposures in Toronto, Canada. JAIDS. 2023 Nov 1;94(3):211-213.
- Billick M, Bogoch I. HIV postexposure prophylaxis-in-pocket. CMAJ. July 2024, 196(24)E826.