Post-exposure prophylaxis-in-pocket (PIP) appears as effective as pre-exposure prophylaxis (PrEP) in improving quality of life (QoL) of individuals at low risk for HIV but may be a less costly option, according to a matched-control study presented at CROI 2026.
Both strategies are highly effective when used appropriately, although PrEP offers continuous protection. However, gaps in treatment still exist for those unwilling to start PrEP or for individuals whose infrequent exposures (1–4 times per year) make them less suitable candidates for PrEP, according to Mia-Eliisa Sapin, an epidemiologist at the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
The better strategy
PIP is a reactive strategy administered within 72 hrs after exposure, whereas PrEP is preventive. PIP remains in reserve and is only taken if an exposure incident occurs, whereas PrEP is taken regularly before potential HIV exposure.
PIP mainly offers convenience by providing a 28-day course of HIV medication that low-risk individuals can start themselves at home and on demand. The WHO now endorses PIP, removing the need for emergency room or clinic visits. However, the researchers noted a lack of real-world data comparing PIP to standard PrEP.
Outcomes for PIP vs PrEP
Researchers compared outcomes for PIP and PrEP regarding sexually transmitted infections (STIs), healthcare costs, and QoL. The study included 32 PIP users prospectively recruited from hospitals and health clinics, who were matched with up to two daily PrEP users of similar age and HIV risk enrolled in the Ontario PrEP Cohort Study (61 individuals). [CROI 2026, abstract 999]
HIV risk was assessed using an adapted HIV Incidence Risk Index for Men who have Sex with Men (HIRI-MSM) score. The median age of participants was 40 years, with a median HIRI-MSM score of 10 in the PIP group and 11 in the PrEP group.
Direct healthcare costs of PIP and PrEP delivery (including drugs, clinic care, and other expenses), diagnosed STIs, and psychological outcomes (such as changes in HIV-related anxiety and sexual satisfaction) were recorded during follow-up visits through e-questionnaires and case report forms. Differences in psychological outcomes were analysed using proportional odds models with standard errors clustered by participants.
Greater savings with PIP
Over a median follow-up of 15 months (12-28 months), 22 percent of PIP users and 38 percent of PrEP users developed STIs. In terms of costs, PIP use was associated with annual savings of up to $1,488 per person (95 percent confidence interval [CI], $1,137–$1,747).
Additionally, the researchers evaluated psychological outcomes related to changes in HIV-related anxiety and sexual satisfaction among PIP vs PrEP users. Although the difference was not statistically significant (p= 0.66), PIP participants showed a slight tendency towards better psychological outcomes, with 32 percent and 29 percent (PIP vs PrEP) moving to a higher outcome category in proportional odds models.
“Overall, for individuals with lower HIV risk, PIP appears to be a less costly alternative to daily PrEP, with comparable rates of STIs and improvements in QoL,” said the researchers.
There were no HIV seroconversions in either group, confirming the efficacy of both PrEP and PIP. However, the researchers acknowledged that the study was not randomized, and confounding factors may exist. Other limitations include the modest sample size and reliance on self-reported outcomes.
Both PrEP and PIP require a prescription from a healthcare professional. Regardless of which approach is chosen, HIV prevention should be tailored to each patient. Additionally, STI screening remains important, they added.