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.