Non-occupational post-exposure prophylaxis does not expand or differentiate candidates for pre-exposure prophylaxis

Background Non-occupational post-exposure prophylaxis (nPEP) has been proposed as a strategic entry point for identifying candidates for HIV pre-exposure prophylaxis (PrEP). However, evidence of its ability to engage at-risk populations beyond gay and bisexual men who have sex with men remains limited. Methods We conducted a retrospective, real-world analysis of all individuals who accessed nPEP at a tertiary care centre in Italy between 2018 and 2025. Demographic and behavioural characteristics were evaluated to identify factors associated with PrEP initiation after nPEP. Results Among the 585 enrolled individuals, 149 (25.5%) initiated PrEP. PrEP uptake was strongly associated with being a gay or bisexual man who has sex with men and with repeated nPEP courses. In contrast, women, individuals aged <25 years, sex workers, transgender women, ethnic minorities and people using recreational drugs showed no increased likelihood of initiating PrEP. The introduction of free-of-charge PrEP did not improve engagement in these groups. Conclusions In this real-world setting, nPEP failed to facilitate PrEP uptake among non-gay and bisexual men who have sex with men at risk of HIV infection. Alternative implementation strategies are needed to increase PrEP access for these diverse key populations.