NPEP use is a good indicator of future HIV risk and acquisition. Australian men who have sex with men who have ever used NPEP are around three times more likely to eventually acquire HIV infection when compared to men who had never used NPEP.^[22] This heightened risk is less about drug failure and more about inability to modify risk or indeed a negative past experience while on NPEP.  The importance of carefully evaluating and choosing the best agents to use as NPEP has been discussed. By employing a variety of behavioural interventions, sexual risk (as measured by condomless anal sex) in men who have sex with men can be reduced, at least in the short term, by about third.^[23]  So referral to appropriate services of men who have sex with men interested in addressing risk behaviour remains important in the new era of ART as prevention. NPEP initiation after a risk event is usually a stressful time and clients often reflect on their risk behaviours thus presenting an opportunity for brief intervention and referral. While behavioural interventions in men who have sex with men interested in change are effective, referral of men who have sex with men uninterested or ambivalent about change is not. Lecturing and scare tactics are equally unproductive. Nurses have an important role in providing a positive, non-judgmental and enabling environment. ‘I’m really glad you’ve presented for assessment’, ‘I’m really pleased you’ve started (re-started) PEP’ are positive and affirming ways to start a client PEP encounter. An HIV-negative man who has sex with men who has difficulty consistently using condoms who is deterred from using NPEP because of health-care provider attitude or censure may become an HIV-positive man who has sex with men who has difficulty consistently using condoms.

NPEP has been the predominant use of ART as prevention in HIV-negative Australian men who have sex with men and others at high risk of HIV infection, however pre-exposure prophylaxis (PrEP) (see below) has the potential to change this situation. NPEP will still, however, have a place as:

• a gateway to PrEP
• an adjunct to PrEP in the context of poor adherence and a high-risk HIV event
• an option for men who have sex with men who are not at high or imminent risk of HIV acquisition (should use PrEP) but who still have intermittent risk events
• a risk reduction strategy for men who have sex with men who choose not to use PrEP
• a risk reduction strategy for men who have sex with men unable to use continous PrEP because of the potential for toxicity (bones/kidneys) related to long-term use.