Truvada for PrEP*

No new serious side effects were observed when Truvada was studied for HIV prevention in clinical trials. Some people may experience nausea, headache, stomach pain, or weight loss. Risk compensation (when people put themselves at greater risk for infection, such as anonymous or multiple sex partners, because they think PrEP will protect them) was not observed in clinical trials. The tenofovir DF (Viread) in Truvada is associated with long-term decreases in bone mineral density (BMD). BMD monitoring should be considered in people who have a history of bone fracture due to a disease or are at risk for osteopenia or osteoporosis. Truvada can cause kidney toxicities. In prevention studies, decreases in BMD and creatinine clearance or eGFR (a marker of kidney function) were rare, mild, and usually reversible upon stopping Truvada. In adolescents, however, BMD-z scores (which compare bone growth to that of matched peers) did not return to baseline. Tell your provider about pain in extremities, persistent or worsening bone pain and fractures, with or without muscular pain or weakness, as well as any concerning changes in urinary habits as these could be signs of bone or kidney problems. If Truvada is discontinued abruptly in people with hepatitis B virus (HBV), flare up of hepatitis may occur—talk to your provider before discontinuing. In studies, there were cases of people who had unidentified HIV infection when starting Truvada for PrEP and subsequently developed drug resistance. A negative HIV test must be confirmed immediately prior to starting Truvada for PrEP. Truvada alone is not a complete regimen to treat HIV. Continuing only with Truvada after acquiring HIV may lead to drug resistance and limit future antiviral options. Truvada contains lactose, which can cause some abdominal discomfort, especially in people who are sensitive to lactose. Truvada for PrEP may cause some weight loss.

Do not take with any other HIV or HBV drugs (including Vemlidy, or TAF) when using Truvada for PrEP. Avoid taking Truvada with drugs that negatively affect the kidneys, including chronic use or high doses of anti-inflammatory drugs for pain like Advil or Motrin (ibuprofen) and Aleve (naproxen). Truvada for PreP can be used with the hepatitis C drugs Daklinza, Harvoni, Sovaldi, Olysio, Viekira Pak, or Zepatier. Truvada should not be given with adefovir. Monitor for tenofovir toxicities if used with Epclusa. Tell your provider or pharmacist about all medications, herbals, and supplements you are taking or thinking of taking, prescribed or not.

Truvada for PrEP is 99% effective in preventing HIV when taken daily as recommended. Stigma and lack of access to health care continue to fuel HIV infections. Individuals should be tested for HIV infection at least every 3 months while taking Truvada for PrEP. CDC PrEP guidelines list non-daily dosing that can be used. This includes PrEP on demand: two pills 2–24 hours before sex followed by one pill 24 hours later and another pill 48 hours later (also called 2-1-1 or intermittent PrEP; GO TO cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-

2021.pdf, SEE pages 55–57). Remember, risk depends on the situation—including where you live. Other problems include not knowing about PrEP and inability to perceive a need for it (not realizing one may have vulnerabilities at all). Although the drug label specifies prevention of sexually-acquired infection, U.S. HIV guidelines also recommend use for protecting against infection through injection drug use (reducing the risk of HIV by more than 70%, according to the CDC). The label notes that risk includes a number of behavioral, biological, or epidemiological factors, including condomless sex, current or past STIs, self-identified risk, having sexual partners of unknown HIV status or unknown HIV viremic status, or sexual activity in a high prevalence area or network. Screening and monitoring requirements include checking for STIs and for hepatitis B and C. Insurers must cover PrEP and its associated services (such as STI testing) without cost (such as co-pays) to people, but the details of coverage can vary and there was a significant legal challenge at the time of publication. The National Alliance of State and Territorial AIDS Directors (NASTAD) developed a guide to help providers bill for PrEP services, available at nastad.org/resource/billing-coding-guide-hiv-prevention. GO TO nastad.org/prep-access for an FAQ. Two excellent websites for finding a PrEP provider are preplocator.org and aidsvu.org—although any provider can prescribe PrEP. Gilead Sciences helps people work with their insurance, including pre-authorizations, as well as provides free PrEP to uninsured people who are eligible, and co-pay assistance up to $7,200 a year; contact the patient assistance hotline at (877) 505-6986, or GO TO gileadadvancingaccess.com. HHS HIV guidelines have a section on using PrEP for periconception, antepartum, and postpartum periods. PrEP Facts: Rethinking HIV Prevention and Sex is a closed Facebook group for people interested in or currently on PrEP, and their allies. For more information, GO TO cdc.gov/hiv/basics/prep.html. Pregnant individuals can voluntarily enroll in the Antiretroviral Pregnancy Registry through their provider; GO TO apregistry.com.

Dr. Melanie Thompson:

Generic TDF/FTC is now available at low cost in the U.S. It should be noted that generic TDF/3TC is not approved for use as PrEP. The adherence challenges of taking a pill a day have always been the Achilles heel of oral PrEP. Headache, abdominal pain and decreased weight were the most common side effects attributable to Truvada in PrEP trials, and a few more people stopped the drug for elevated creatinine or protein in the urine in the Truvada arm than the placebo arm. Bone density decreased more on Truvada than placebo, but the incidence of fractures was low and similar in both arms. In spite of this, Truvada remains a safe and effective PrEP option for most people, especially younger people without preexisting kidney disease or low bone density. It should be noted that tenofovir levels are increased with the hepatitis C drug Harvoni (ledipasvir/sofosbuvir) and close monitoring of TDF-related toxicities is recommended. People with hepatitis B may experience a hepatitis flare if Truvada or TDF/FTC is stopped without other drugs on board to treat hepatitis B. For insured individuals, there should be no out-of-pocket cost for the drug or PrEP services (office visits, lab monitoring including STI screening) due to an “A” rating from the U.S. Preventative Services Task Force (USPSTF). We badly botched the rollout of PrEP in the U.S.; far too many people who could benefit still lack access to PrEP, with wide disparities by race, ethnicity and gender.

Activist Joey Wynn:

Truvada—although controversy abounds, this work horse has helped many a person maintain their viral load back in the day, and now it can help reduce the chances of acquiring HIV. Still a viable option, TDF has some side effects, but so do the other options. Have several conversations with a variety of medical professionals before deciding which prevention option is right for you. TDF may be better than TAF when it comes to cholesterol and weight gain; this remains the first choice for PrEP for many people, including people who are contemplating pregnancy.  Remember, even if your only option is generic Truvada, it will work well, too.