PrEP and PEP: What Hospitalists Need to Know

Although it may not always be top of mind for hospitalists, discussing or prescribing pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) for human immunodeficiency virus (HIV) can become a valuable part of a patient’s hospital stay.

Dr. Holloway

“Because of systemic barriers, time constraints, and ongoing stigma, opportunities to identify and protect patients at risk for HIV are often missed during a hospitalization. It’s essential that hospitalists are equipped to recognize eligible patients and feel comfortable initiating discussions about HIV prevention,” said Rachel Holloway, MD, an internal medicine-pediatrics PGY-3 at the University of Cincinnati in Cincinnati.

The Hospitalist interviewed several physicians about PrEP and PEP treatments, why PrEP and sometimes PEP may not be discussed with patients, how to broach the PrEP discussion, and how to help patients get consistent with PrEP and PEP medication use.

The Basics of PrEP and PEP

When used as prescribed, PrEP lowers the risk of getting HIV infection from sex by 99%, according to the Centers for Disease Control and Prevention (CDC).¹ For people who inject drugs, PrEP can lower the risk of HIV infection by at least 74%.¹

There are four drugs available for PrEP, two of which are oral and two of which are injectable:

• Emtricitabine/tenofovir disoproxil fumarate (Truvada), an oral medication approved for daily use for anyone at risk of HIV through sex or injection drug use. Truvada also has a generic form.
• Emtricitabine/tenofovir alafenamide (Descovy), also an oral medication used daily. It’s not geared toward those having receptive vaginal sex because researchers have not evaluated the drug’s effectiveness in this population.
• Cabotegravir (Apretude), an injectable medication administered every other month, is designed for both adults and teens at risk for HIV through sex.
• Lenacapavir (Yeztugo), an injectable medication administered twice a year to those at risk for HIV through sex, although there is a starter dose that includes oral medication.

Both of the injectable medications are offered in a practitioner’s office and are not for self-injection.

Patients starting PrEP need a negative HIV test before initiation. Other lab tests include a pregnancy test if applicable, sexually transmitted infection (STI) screening, and kidney function and hepatitis B testing.

Those using the oral form of PrEP must see a physician every three months to get another HIV test and to get a medication refill. Those using the injectable form will return to their physician’s office at regular intervals for the injections and any other follow-ups needed, including HIV tests.

CDC guidelines recommend the use of PrEP for those who:

• Have had anal or vaginal sex in the previous six months and have had a sexual partner with HIV, have not consistently used a condom, or have been diagnosed with an STI in the previous six months
• Have injected drugs and have an injection partner with HIV or share needles, syringes, or other drug injection equipment; and
• Have been prescribed PEP for multiple courses, or who have used PEP and also continue risk behaviors
• Patients who inquire about PrEP and don’t have the factors above may also use PrEP as long as they don’t have HIV.²  The CDC recommends that physicians prescribe PrEP to anyone who asks about it, even if they don’t have any known risk factors.³

Dr. Watson

James R. Watson, MD, is an assistant professor in the department of medicine’s division of hospital medicine at Duke University and an attending hospitalist at Duke University Hospital, both in Durham, N.C. He recently did PrEP research to expand its use at his hospital and was surprised to see how broad the recommendations are.

“That doesn’t necessarily mean everyone who is sexually active has to or should be on it, but the conversation should be had,” he said. Having that discussion in the hospital can be valuable, particularly at safety-net hospitals that help those without regular primary care, he said.

PEP is given as oral therapy and usually involves three drugs taken for 28 days by those who have had potential exposure to HIV within the previous 72 hours. This includes exposure through sex or through a needlestick injury. However, those using PrEP medications consistently do not require PEP if potentially exposed to HIV.

Before starting PEP, patients should have a negative rapid HIV test and a negative pregnancy test. Other labs to perform include a serum liver enzyme test, a blood urea nitrogen and creatinine test, STI screening, and hepatitis B and C tests. However, it’s okay to start PEP before you get all of the patient’s lab results, according to the CDC.³

Once a patient finishes PEP, they can transition to PrEP so long as they remain HIV-negative.

When and Why PrEP Is Under the Radar

The use of PrEP may remain under the radar for some hospitalists if it doesn’t come up naturally during a patient’s hospital stay.

Dr. Keaster

“Guidelines recommend discussing PrEP with all sexually active individuals, so it starts with a good sexual history. We often see that sexual history takes a backseat to other elements of the history, especially when clinicians are busy,” said Andrew Keaster, MD, hospitalist and associate professor at The Ohio State University in Columbus, Ohio. Dr. Keaster specializes in hormone therapy and transgender care and is a co-founder of The Ohio State’s transgender primary care clinic.

There may also be confusion over who should use PrEP.

Dr. Schoenberger

“It’s easy to cite risk factors as reasons to offer PrEP to patients, but the reality is that we should be offering PrEP to many more folks than we often think,” said Alexandra Schoenberger, MD, MSEd, an internal medicine-pediatrics chief resident at the University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Center in Cincinnati.

Dr. Watson has found through his research that awareness of PrEP was more common among men having sex with men and that this population of patients was more likely to have a prescription for it, compared with people who inject drugs. In his discussions with patients in the latter group, he found they may be aware of their higher risk for HIV and the importance of clean needle programs, but they may not be aware of PrEP medications.

A lack of awareness about PrEP among patients and sometimes medical practitioners may be why the use of PrEP is lower than it could be. CDC data from 2022 found that only 36% of the 1.2 million Americans who could benefit from PrEP were prescribed it. Although that was an increase compared with 23% in 2019, there was still a big gap between white patients who were prescribed it versus Black and Latino patients.⁴

Hospitalists may have some awareness of PrEP, but do not know about the various options available for treatment. Then, there’s the follow-up factor. With hospitalists often focused on inpatient care, a medication that requires HIV testing every three months (to ensure the patient does not have HIV while using PrEP) may seem like it’s out of their purview.

Dr. Hazra

“I think it takes a little more digging or nuance in thinking about how PrEP can be integrated into hospitalist care,” said Aniruddha (Anu) Hazra, MD, an associate professor of the section of infectious diseases and global health, director of the infectious diseases fellowship program, and medical director of the UCM Sexual Wellness Clinic in the department of medicine at the University of Chicago in Chicago.

Dr. Baker

“A lot of hospitalists are going to be hesitant and say, ‘PrEP is not in my wheelhouse. Should I be starting it if I’m not following up on it?’” said Dylan Baker, MBBS, an assistant professor with the Emory University department of medicine, medical director at Emory Grady Primary Care Center, and associate medical director in the Grady HIV Prevention Program at Emory University, all in Atlanta. Still, Dr. Baker thinks it’s useful to prescribe PrEP when called for and to help schedule a follow-up with outpatient services, so long as the patient has a negative HIV test.

Broaching the Topic

There are a few ways to broach the topic of PrEP with patients without making them feel stigmatized:

• Normalize questions about sexual activity and substance abuse while taking an admissions history, Dr. Holloway said. “Set up the conversation as a regular screening process and use open-ended questions about sexual practices and substance abuse,” she said.
• Discuss the topic or broach it again after the acute reason for hospitalization has been stabilized. This may require coming back in the afternoon after rounds and waiting until visitors are not present, Dr. Holloway said.
• Approach discussions of HIV prevention as a routine part of preventive healthcare. Dr. Hazra likens PrEP to prescribing a statin for someone with high cholesterol or metformin for a patient with diabetes. Here is one way to frame PrEP that Dr. Schoenberger recommends, particularly when a patient does not have a regular primary care physician: “Looking through your chart, I noticed that you don’t follow with a primary care doctor yet. Based on your age and history, there are a few things I would like to discuss to keep you healthy and, ideally, out of the hospital. One of them is a medication called PrEP, which can help prevent you from getting HIV in the future. Would you be open to learning more about it in the hospital while we work to connect you with an outpatient healthcare team?”
• Avoid the use of shame-based or fear-based language. “For example, using the term ‘increased risk’ rather than ‘high risk’ can help foster a more patient-centered, nonjudgmental approach,” Dr. Holloway said. Another example from Dr. Keaster: Avoid statements like “I think what you’re doing is risky” or “I’m worried you’ll get HIV if you don’t get on PrEP.” Instead, try: “PrEP gives you control over your sexual health” and “PrEP is an extra layer of protection to help keep you protected from HIV.”
• Offer to discuss PrEP with any sexually active adult or any adult who requests it, or with any adult who injects drugs or uses substances, Dr. Schoenberger said. This helps PrEP to reach more people and also decreases the risk that the physician’s own biases will negatively impact access.
• If a patient appears overwhelmed by the discussion of PrEP, drop the topic and come back to it later. Or recommend a post-discharge follow-up that includes the discussion of HIV prevention.
• Expect a range of potential reactions when discussing PrEP and PEP. This could include relief, curiosity, hesitation, resistance, or concern about stigma and judgment, Dr. Holloway said. Some reactions may reflect a lack of understanding about personal risk factors or the side effects of PrEP or PEP, mistrust of the medical system, and lack of established outpatient care. Use your time with the patient to address questions and concerns.
• Help patients identify other resources where they can learn about PrEP. For example, you may have colleagues in or out of the hospital who can provide more PrEP education, Dr. Hazra said. Identifying PrEP champions in your hospital also may help you or other hospitalists learn more about PrEP, he said. There are also websites like PrEPlocator.org where patients can find out where to get PrEP, Dr. Keaster said.
• Normalize the discussion of other types of prophylaxis, including the use of barrier methods like condoms, Dr. Baker said.

Discussing PEP is often more straightforward, as a patient might be at the hospital due to an STI or potential exposure to HIV. Hospitalists can start patients on PEP but also broach the PrEP discussion at or around the same time.

If a patient already uses antiretroviral therapy and you are doing a medication reconciliation, confirm if the patient is using their therapy for PrEP, PEP, HIV treatment, or hepatitis B, Dr. Holloway said. There may be reasons to temporarily stop therapy, such as acute kidney injury or significant drug-drug interactions.

“At the same time, be mindful of situations in which therapy should be continued, as unnecessary interruptions may reduce effectiveness or, in the case of hepatitis B co-infection, risk viral reactivation,” she said.

Helping Patients Get Consistent

One advantage of PrEP is that there are different ways to take it, which means that patients can choose the option that will help them the most with adherence.

PrEP (and PEP) are also usually covered by private insurance, as well as Medicare and Medicaid. Uninsured patients may qualify for patient assistance programs from manufacturers.

Emphasize timeliness when discussing PEP with patients who need it, including starting therapy within 72 hours after exposure and finishing the full 28-day course of the medication. Make patients aware of mild side effects, such as gastrointestinal symptoms that will likely improve.

“Preparing patients with realistic expectations ahead of time can enhance the likelihood of regimen adherence down the line,” Dr. Holloway said.

Here are a few tips to share with patients so they can stay on track with adherence, even if you, as the hospitalist, won’t monitor this long-term:

• Suggest pairing oral medication with another habit, such as brushing their teeth or eating breakfast.
• Let patients know about the variety of electronic reminders available via apps and their phones.
• Help to set up appointments with a practitioner while the patient is still in the hospital. Although you can’t guarantee they will go to the appointment, having something set saves the patient a step.

Wrapping It Up

Even if a patient decides that PrEP isn’t for them for now, hospitalists still play a role in opening the discussion door on the topic of prophylaxis.

“Planting the seed by starting the conversation and educating patients about these options can be life-changing in the long term,” Dr. Holloway said. n

Vanessa Caceres is a medical writer in Bradenton, Fla.

References

1. U.S. Department of Health and Human Services. Pre-exposure prophylaxis. HIV.gov website. https://www.hiv.gov/hiv-basics/hiv-prevention/using-hiv-medication-to-reduce-risk/pre-exposure-prophylaxis. Accessed April 23, 2026.
2. U.S. Centers for Disease Control and Prevention. Preventing HIV with PrEP. CDC website. https://www.cdc.gov/hiv/prevention/prep.html. Updated April 15, 2026. Accessed April 23, 2026.
3. U.S. Centers for Disease Control and Prevention. Clinical guidance for PEP. HIV Nexus: CDC Resources for Clinicians website. https://www.cdc.gov/hivnexus/hcp/pep/index.html. Published February 10, 2025.  Accessed April 23, 2026.
4. U.S. Centers for Disease Control and Prevention. Expanding PrEP coverage in the United States to meet EHE goals. CDC National Center for HIV, Viral Hepatitis, STD, and Tuberculosis Prevention website. https://www.cdc.gov/nchhstp/director-letters/expanding-prep-coverage.html. Published October 17, 2023. Accessed April 23, 2026.