Some definitions

PrEP: pre-exposure prophylaxis - referring to a daily medication taken to prevent the acquisition of HIV

PEP: post-exposure prophylaxis - referring to a combination of medications taken after a potential exposure to HIV in order to reduce the likelihood of transmission

Who should take PrEP?

People who have condom-less anal sex

People who have sex partners they don't know very well or whose partners know they have HIV

People who come from communities that have a greater burden of HIV because of less access to care and other systemic barriers

Anyone who has had a bacterial sexually transmitted infection, like gonorrhea, chlamydia, or syphilis in the past six months

Why is PrEP special?

PrEP is a powerful form of prevention that allows people to have autonomy and make decisions about their own sexual health

PrEP is not only a medication that prevents HIV, but it's also a very emotionally significant drug for many. For those who feel the legacy of the AIDS crisis of the 1980s and 1990s, having an HIV prevention drug can provide agency and control 

It can serve as a gateway into lent-term primary care (which we here at QHP are big fans of!)

A brief PrEP timeline

In 2012, Truvada (otherwise known as tenofovir/emtricitabine/TDF) - a medication previously used to treat HIV - was approved by the FDA for PrEP, or to prevent HIV.

It became apparent that Truvada as PrEP worked. The first big study looking at Truvada showed that daily PrEP lowered the risk of getting HIV by 92% if exposed.

Slowly but surely, the queer community got on board (with the help of groups like PrEP Facts). More and more people began using PrEP to prevent HIV transmission.

2019: a scientific trial called the DISCOVER trial published preliminary data

It investigated the possibility of a second PrEP medication, another HIV medication called Descovy (otherwise known as tenofovir/emtricitabine/TAF)

It also suggested that Descovy may have a better side effect profile

Based on the preliminary data, the FDA approved Descovy as a second PrEP option. Some folks started getting switched from Truvada to Descovy (with or without their consent).

At which point many people started wondering: which PrEP medication to opt for? Which is the better option?

Truvada vs. Descovy: the scientific data

When Truvada came onto the scene as PrEP, it did so with multiple large studies of high quality evidence and in multiple populations

iPrEx: a study that put Truvada on the map. Studied side effects and efficacy at HIV prevention in men who have sex with men as well as transgender women.

Partners PrEP: showed that Truvada was effective at HIV prevention within heterosexual couples where one partner is HIV+

Descovy, in turn, so far has less scientific literature discussing its efficacy as PrEP in a variety of populations

Basically, all we have is the DISCOVER trial - which only looks at cisgender men and some trans women

And note: up until 2020 (a year after FDA approval) the DISCOVER trial had not officially released its data, just a preliminary abstract

It’s unusual that Descovy was such a popular and widely-used option before the data was officially published – before healthcare providers could read the data for themselves and help their patients make informed decisions

In addition to the above differences in how the drug came to the market, Truvada has an additional study (called IPERGAY - you can’t make this stuff up)

 This study demonstrates Truvada’s efficacy as PrEP “on demand” – meaning, taken in the days right before and right after a sexual encounter

Descovy, in turn, has no such data supporting its use as PrEP on demand

Truvada vs. Descovy: side effects

Truvada

Abdominal discomfort: observed in roughly 1 out of 5 people. Usually goes away on its own after two to six weeks on medication

Changes in kidney function (as measured via a substance called creatinine), largely reversible

Changes in bone density - also reversible once taken off the medication

Descovy

Based off of what we know about Descovy as HIV treatment, it can increase cholesterol, blood sugar levels, or weight gain, risk factors for the development of heart attack and stroke.

Unclear if these effects will be seen or will have impact on people’s health in the long-term when Descovy is used as PrEP given that the drug is dosed differently in this context.

The DISCOVER data also suggests that there  may be fewer kidney and bone side effects -

So who actually should be taking Descovy as PrEP?

As of right now, the medication is approved in cisgender men who have sex with men. It is not approved for folks with vaginas, since that group was not studied in the DISCOVER trial.

Ultimately, the decision is an individualized one that depends on personal medical history and preferences. For example: for folks with kidney disease, Descovy may be a better option. 

Long story short: it depends. Bring it up with your primary care provider! (And if you don’t feel comfortable bringing it up, we encourage you to find a care provider  with whom you do feel comfortable – all while acknowledging that this is likely far easier said than done.)

A generic PrEP option

Truvada’s patent expired in 2019, at which point it became generic. How does having two PrEP options – one brand name, one generic – change the HIV prevention landscape?

The good

On face value, having a generic PrEP option seems like a good thing since it will increase financial access. 

Additionally, having two options gives folks agency, which may increase PrEP uptake

However…

Having a fancy brand name option (Descovy) may stigmatize the generic option (Truvada). This is tricky for folks who only have generic options available to them.

One drawback is that the Gilead co-pay assistance programs will not pay co-pays so there may be some back and forth with providers, insurance and pharmacies as this transition occurs.  However, there should always be an option to have PrEP covered.