Emergency department HIV pre-exposure prophylaxis (PrEP) referral program

Baltimore, USA

A hospital emergency department (ED) implemented a pilot program that integrated PrEP referral within their HIV screening process to increase the use of PrEP. PrEP is highly effective at preventing HIV but is currently underutilized. This program assessed ED patients for PrEP eligibility, and if patients were deemed eligible and interested in PrEP, they were referred to a peer navigator. Of the 119 patients approached about PrEP, 33% expressed interest in a PrEP referral and 74% of those patients were successfully contacted by a peer navigator. Of those who were contacted by a peer navigator, 41% made a PrEP appointment and 10% successfully initiated PrEP.

Program description

The ED PrEP referral pilot program took place from December 2018 to April 2019. Anyone 12 years of age or over who visited the ED received opt-out, non-targeted HIV testing. Patients qualified for the PrEP referral program if they met at least one of the following criteria (determined through a chart review process):

  • received a negative HIV test result during the current visit or within the last two months
  • had a laboratory test performed for a sexually transmitted infection (chlamydia, gonorrhea, trichomoniasis and syphilis) during the current ED visit or within the last 2 months, with the result indicating an increased risk for HIV

If they qualified for the PrEP referral program, patients were approached by a program assistant who asked if they were interested in receiving HIV education. If they were interested, patients completed a verbal or self-administered electronic PrEP referral assessment tool. The tool included an HIV risk evaluation, a PrEP knowledge evaluation, a PrEP interest evaluation and an assessment of the patient’s perceptions of and attitude about PrEP referral.

If patients were interested in PrEP, the program assistant referred them to a peer navigator. If they were not interested in PrEP, the program assistant provided informational brochures. ED staff were educated about the pilot and were permitted to refer people to the program if they could fit this task into their primary job responsibilities, but they were not required to do so.

Patients who were interested in receiving PrEP were immediately connected to a peer navigator. During daytime business hours, the navigator came to the ED. If potential PrEP patients were at the ED after hours, a peer navigator followed up with them within 24 hours. The peer navigator provided PrEP counselling and education, in addition to scheduling a PrEP clinic appointment for those who were interested.


There were 314 ED patients that qualified for the PrEP referral program through the chart review process. Of those patients, 162 (52%) were approached by program assistants in the ED. The top reasons for not approaching a patient included the following: the patient was with family (26%), the patient was being discharged (18%) or there was a language barrier (16%).

Of those approached by the program assistant, 119 (73%) expressed interest in further HIV prevention education. The majority of the patients approached by the program assistant were female (57%) and African American (66%). Of those who expressed interest in HIV prevention education, 110 completed a PrEP referral assessment and approximately 76% had no prior knowledge of PrEP.

Of the 119 patients interested in HIV prevention education:

  • 39 (33%) expressed interest in PrEP referral
  • of those, 29 (74%) were successfully contacted by peer navigators either in person or via phone
  • 16 (41%) of the patients who expressed interest in PrEP referral were scheduled for a PrEP clinic appointment
  • 4 (10%) completed the appointment and successfully started PrEP

What does this mean for service providers?

This pilot program shows that referral to PrEP can be successfully done in an ED and can be integrated within an existing HIV screening protocol. One of the major concerns of this approach was the drop-off from referral to initiation of PrEP, an issue that has been seen in other PrEP referral programs. The need to close the gap between the intention to start PrEP and actually beginning PrEP has been noted by other researchers. This could be addressed through approaches such as motivational interviewing and strengths-based case management.

This pilot program took place in a hospital with strong HIV testing and linkage to care protocols, which meant that the ED had strong connections to PrEP clinics. This may not be the case in all EDs and may therefore limit the success of similar programs.

In addition to integrating PrEP referral programs into EDs, service providers could also consider integrating them with testing for HIV and sexually transmitted and blood-borne infections in other community settings, such as sexual health clinics and community health centres.

Related resources

The Maple Leaf PrEP Clinic

Project Sexual Health Equity (Project SHE): Pre-exposure prophylaxis (PrEP) for women who inject drugs

Same-day HIV Pre-Exposure Prophylaxis in an urban sexually transmitted infection clinic


Zhao Z, Jones J, Arrington-Sanders R et al. Emergency department–based human immunodeficiency virus preexposure prophylaxis referral program—using emergency departments as a portal for preexposure prophylaxis services. Sexually Transmitted Diseases. 2021;48(8):e102-e104.