Research Summary

Emergency Department PrEP Initiation Does Not Improve Uptake or Retention in Pilot Trial

Miranda Manier, BA

Key Highlights

  • In a pilot randomized controlled trial, immediate initiation of pre-exposure prophylaxis (PrEP) in the emergency department (ED) did not increase PrEP use or retention in care compared with referral to outpatient services.
  • At 90 days, only three participants (two in the ED initiation group and one in the referral group) were taking PrEP.
  • Barriers to ED-based PrEP initiation included low patient interest and limited awareness, despite high satisfaction with the screening process.

A pilot randomized controlled trial evaluating whether initiating HIV pre-exposure prophylaxis (PrEP) directly in the emergency department (ED) increases uptake compared with referral to outpatient services found no improvement in PrEP usage or retention, highlighting ongoing challenges to implementing PrEP in this high-risk setting.

PrEP is highly effective at preventing HIV transmission, yet remains underutilized due to multiple barriers, including limited awareness, provider hesitancy, and structural inequities. The ED represents a potential venue for reaching individuals at elevated risk who may be disconnected from primary care. However, the feasibility and effectiveness of initiating PrEP at the point of ED care remain unclear.

In this study, 1455 patients were screened, 169 were eligible, and 27 were randomized. Participants were assigned 1:1 to receive either immediate PrEP initiation (iPrEP) in the ED with a 28-day starter pack at discharge or referral to outpatient services for initiation. The primary outcome was PrEP usage at 90 days, with secondary outcomes including PrEP usage at 30 and 60 days, retention in care across all time points, HIV risk, and satisfaction.

Of the 27 randomized participants, 26 received the assigned intervention. At 90 days, PrEP usage remained very low, with only three participants continuing therapy (two in the iPrEP arm, one in the referral arm). No significant differences were found between the groups at 30, 60, or 90 days for any secondary outcomes. Although participants expressed high satisfaction with the screening process, low interest in and awareness of PrEP persisted as barriers to initiation and continuation.

 “PrEP initiation in the ED did not improve PrEP usage or retention in care compared with referral alone,” Cowan and colleagues concluded. “Despite high satisfaction with the screening process, barriers to ED-based PrEP initiation, including low interest and awareness, persisted.”

Reference
Cowan E, Eiting E, O'Brien-Lambert C, Ryder J, Calderon Y. A randomized controlled trial of HIV pre-exposure prophylaxis provision in the emergency department (PrEPPED). J Emerg Med. 2025;75:278-288. doi:10.1016/j.jemermed.2025.03.001