Non-occupational postexposure prophylaxis (NPEP)

NPEP has been in wide-spread use in Australia since 1999 and is recommended by the Australian Government’s Department of Health and Ageing.[11] The Australian National NPEP guidelines recommend 28 days of ART (at prescriber’s discretion) with two or three drugs for an HIV transmission risk event of ≥ 1: 15,000. Australian men who have sex with men and, to a lesser extent, people who inject drugs, are the principal target groups.  Nurses have diverse roles in the assessment and provision of PEP (see Table 12).  Any nurse working in HIV and sexual health, family planning, an emergency department or in a general practice requires a minimum of PEP literacy (see Table 13).

Table 12: Nursing roles in non-occupational postexposure prophylaxis (NPEP)

  • Management of statewide services
  • NPEP assessment, initiation and care in emergency departments and sexual health and HIV care settings
  • NPEP hotlines
  • NPEP research
  • Participating in development of state and national guidelines
  • Providing education and support.

Table 13: Minimum post-exposure prophylaxis (PEP) literacy

  • What constitutes a risk event – how to assess risk
  • How to access help (PEP hotlines, emergency departments, sexual health clinics, HIV care providers, overseas)
  • The importance of timing – NPEP should be started as soon as possible after a risk event
  • The duration of therapy
  • Adherence education and support
  • The need for a high level of adherence to the regimen
  • Choosing the optimum dosing time based on the patient’s routine work and leisure patterns including discussion about the dosing window – a rigid, fixed time to dose sets patients up to miss a dose and fail
  • Strategies to assist adherence – teaching cueing (the act of associating pill taking with a habitual behaviour), visual and electronic reminders, pill boxes, preparing for the unexpected: for example, keeping a supply at work, in the car, in a bag, at a friend’s house.
  • What to do if a dose is missed
  • Likely regimen related side-effects
  • What to do and how to access help if side-effects occur
  • The nurse can provide the first port of call and access to help by encouraging re-presentation and providing telephone access and support

Most potential exposure to HIV occurs outside business hours or over a weekend.  In 2017, 51% of HIV risk events prompting assessment for NPEP at St Vincent’s Hospital, Sydney occurred on a Saturday or Sunday. Of the 170 (49%) that occurred during a week day, 10% were between the hours of 08:30 and 17:00; the usual operating hours of clinics that provide NPEP. Thus, emergency departments assess the majority of presentation for NPEP and nurses who work in emergency departments are a particular group who need to be PEP literate.

In addition to a minimum PEP skill set, nurses provided with adequate training, support and resources are also capable of independently assessing and managing patients requiring ART as PEP.

The National NPEP Guidelines provide comprehensive information about risk assessment, in brief:

  • an HIV risk event needs to have occurred
  • the person with whom the event occurred needs to be HIV positive or from a population likely to have HIV
  • the patient needs to present for assessment within 72 hours of the event

Table 14 presents a simple flow-chart which can be used as a NPEP risk assessment tool.

Table 14: Non-occupational post-exposure prophylaxis (NPEP) risk assessment#

 Consider NPEP if conditions 1, 2 and 3 are met


High-risk exposure

  • Condomless receptive intercourse (anal or vaginal)i
  • Condomless insertive intercourse (anal or vaginal) i
  • Use of contaminated injecting equipment

Condomless means no condom used or condom slippage or breakage

Notes: Condomless receptive oral intercourse with ejaculation MAY BE CONSIDERED as a high-risk exposure providing the source is known to be HIV positive with a detectable HIV viral load and there is oral mucosal disease or an open lesion in the mouth or throat.

Significant exposure of non-intact skin with blood, sperm or vaginal fluids MAY ALSO BE CONSIDERED as a high-risk exposure providing the source is known to be HIV positive with a detectable HIV viral load.



Source is known to have HIV infectionii


Source is likely to be at increased risk of HIV

      • Men who have sex with men
      • Heterosexual person who injects drugs
      • A person from a high HIV prevalence country (HIV prevalence > 1.0%)iii
      • A sex worker OUTSIDE of Australia

ii NPEP is NOT RECOMMENDED following insertive or receptive anal, vaginal or oral sex, sharing of needles or other injecting equipment, and mucous membrane and non-intact skin exposure when the source’s viral load is KNOWN to be undetectable – this is provided the source is known to be compliant with medication, attends regular follow-up and has no intercurrent sexually transmissible infection (STI).

iiiData available at:




The client presents within 72 hours of exposure

1  +  2  +  3  =  NPEP

For a comprehensive guide to risk assessment see the Australian National NPEP guidelines available at:

NPEP does not always prevent HIV acquisition. The time to first NPEP dose, incomplete NPEP adherence, continued HIV risk behaviour and primary ART resistance have each been linked to NPEP failure.[12] [13]