HIV PrEP

In this section, our expert doctor will answer questions about a few aspects of PREP. We have reviewed real-life patient questions and grouped them into topics. Dr. Fuzayloff has been a practicing physician at a busy STD testing center in Midtown Manhattan, NYC, for over two decades.

• Which medication should I choose for PrEP?

  The two medications are comparable with respect to HIV protection. The difference between them is their potential side effects with prolonged use.

  Most people

  Most people are advised to take Truvada or a generic version of it (tenofovir disoproxil fumarate-emtricitabine). It has been on the market longer and is better studied for various groups.

  Teenagers

  Descovy is the preferred medication for teenagers, who are at higher risk of loss of bone mineral density during the growth phase of bone development.

  Older people

  Descovy is the preferred medication in some people who are at risk of osteoporosis (which can be confirmed by a simple test called a DEXA scan).

  Females and transgender people

  • In terms of HIV protection for women and transgender people, Truvada is the preferred medication because more studies have been done with this medication with people having vaginal sex.
  • Most studies for Descovy were done with people having anal-receptive sex. The concentration of the PrEP medication in anal tissue and vaginal tissue is different and needs to be studied independently.
  • Other factors, such as age and whether the condition is chronic, should be considered in decision-making.

  Weight gain

  Descovy is associated with weight gain that is very mild but greater than with Truvada.

  High cholesterol

  Descovy is associated with very mild but greater unfavorable change in cholesterol, unlike Truvada.

  Kidney disease

  For people with kidney disease and abnormal kidney function tests, Descovy is the preferred medication. It should be started after a consultation with a kidney specialist (nephrologist).

• How soon is the medication effective?

  How soon after the medication is initiated it will be effective depends on the type of sexual activity the person is engaging in, receptive rectal or vaginal sex. The medication must build up an adequate concentration in the tissue to be effective, and this is different for the two areas:

  Insertive anal sex

  • No data available

  Receptive rectal sex

  • Seven days after starting the medication, adequate protection is achieved.

  Insertive vaginal sex

  • No data available

  Receptive vaginal sex

  • Twenty-one days after starting the medication, adequate protection is achieved.

  Note that condom use is encouraged even for people taking PrEP taking because of the risk of other STDs and hepatitis C.

• How effective are HIV PrEP medications?

  The effectiveness of the medication depends on the following:

  • the type of medication (Truvada or Descovy)
  • the type of sexual activity (rectal or vaginal)
  • the patient’s adherence to the medication regimen

  Medication type

  Both medications, Truvada and Descovy, are very effective in terms of HIV protection.

  • Truvada is 99.4% effective
  • Descovy is 99.7% effective

  Types of sexual contact

  • PrEP is more effective for rectal receptive sex than for vaginal receptive sex because the medication reaches a higher and steadier concentration in rectal tissue than it does in vaginal and cervical tissues.

  Taking medication daily

  • Taking either medication daily without missing a dose is the most important factor in its effectiveness.

• Will it really matter if I miss a pill now and then?

  It’s very important not to miss a dose of the medication because it’s critical to achieve adequate drug concentration. This is the single most important factor in the effectiveness of PrEP medications (not which medication you take).

  One dose per day

  • If you miss a dose, take it as soon as you remember that day.
  • Take only 1 dose per day.
  • Do not take 2 doses to make up for what you missed.

  Am I still protected if I miss a PrEP dose?

  The answer to that question depends on whether you’re having anal or vaginal sex. An adequate concentration of medication in the rectal area can be achieved with fewer doses than in vaginal area:

  Anal receptive sex

  • Four doses a week give a high level of protection

  Vaginal receptive sex

  • Six or seven doses a week are needed for adequate protection

  This table shows the effectiveness of PrEP medication based on the number of pills taken per week, based on an iPrex study:

  Pills per week	PrEP effectiveness
  7	99%
  4	96%
  2	76%

• How long will I have to take PrEP?

  PrEP should be continued as long as the risk of getting HIV persists:

  • If you don’t always use a condom
  • If you have a partner with an unknown HIV status
  • If you have or have had a sexually transmitted infection (STI)

  Please refer to the beginning of the chapter to see the complete list of risk factors.

  
  

  If you’re no longer at risk of contracting HIV, you can continue taking the medication for a month and then stop it. Ideally, you should have an HIV test upon discontinuation of PrEP.

  If your partner is HIV-positive

  If your partner is HIV-positive, you should continue on PrEP until your partner’s viral load is consistently and stably suppressed (undetected) for six months. If there is any doubt about whether your partner is taking HIV suppressive medication consistently, you should continue on PrEP.

• Will taking PrEP increase the chance that I’ll get another STI?

  Many people who start taking PrEP medication engage in high-risk activity and do not use condom. The chance of getting other STDs is higher for these people, especially homosexual males. Approximately 30% to 50% of such people get another kind of bacterial STD within a year.

  
  

  For that reason, using condoms (or another barrier protection) is encouraged.

• Do PrEP medications have side effects?

  A very small number of people who take PrEP medication stop taking it because of side effects:

  • 1% of people stopped Descovy
  • 2% stopped Truvada

  The table below shows the most common side effects for both medications after 1 year of taking it. As you can see, the two medications are comparable with regard to the most common side effects.

  Side Effects	Descovy	Truvada
  Diarrhea	5%	6%
  Nausea	4%	5%
  Headache	2%	2%
  Fatigue	2%	3%
  Stomach discomfort	2%	3%

  Serious side effects

  Descovy had less impact than Truvada on bone mineral density and kidney function lab tests in the DISCOVER trial.

  
  

  Kidney side effects

  • A kidney test for creatinine should be done every three months. If creatinine is becoming abnormal because of the medication, it usually goes back to normal once the medication is discontinued.

  Bone mineral density

  • Bone mineral density is a good gauge of bone health. Whether a bone scan is needed before and after starting PrEP is unclear at this point and that decision is made on a case-by-case basis

• Are there alternatives to taking pills every day?

  There is an option for people who don’t like taking medication daily or who aren’t sexually active enough to be on PrEP medication all the time.

  
  

  It’s called on-demand dosing. There are two medication regimen—the choice depends on gender and the type of sexual activity.

  Option one

  The first option is good for males and females having vaginal sex.

  • Begin taking daily PrEP one week in advance (heterosexual males) or three weeks in advance (females)
  • Continue taking the daily medication while at risk and 30 days after the last risky encounter

  Option two (“2-1-1”)

  The second option is also called “2-1-1 PrEP.” It is mainly for people practicing rectal receptive sex.

  • Two tablets taken 2 to 24 hours before sexual activity
  • Continue taking one tablet daily while active and at risk and for two more days after the last contact.

  Disadvantages of on-demand approaches

  There are disadvantages to on-demand PrEP, especially the 2-1-1 approach:

  • Not enough studies to confirm effectiveness since it is relatively recent regimen
  • Not approved by FDA (but mentioned by World Health Organization)
  • Hard to remember to take the medication since it’s not taken every day

  *People with chronic hepatitis B infection cannot take the medications.

• How much does PrEP cost? Is it covered by insurance?

  Cost is always a factor that needs to be considered during the decision-making process. Here we will tell you what financial assistance you can get with PrEP for the most common situations.

  If you have commercial health insurance

  The Gilead Advancing Access co-pay coupon card might help you save. For some people, that could mean paying as little as $0. Visit GileadAdvancingAccess.com for that card.

  If you have government insurance

  If you have government insurance (such as Medicaid or Medicare), you are not eligible for the Gilead Advancing Access co-pay coupon card. However, Gilead Advancing Access may be able to provide information about financial support through alternative sources of funding.

  If you don’t have insurance

  You may be able to receive PrEP if you qualify for the Medication Assistance Program. Gilead Advancing Access should help you determine if you qualified for this program.

  
  

  Public health clinic and LGBTQ clinics may be able to lower the cost of your visits. Go to cdc.gov/lgbthealth/health-services.html or HIV.org.

  
  

  Enroll at: GileadAdvancingAccess.com or call 1-800-226-2056.