What are the different Pre-Exposure Prophylaxis (PreP) options, including Truvada (emtricitabine/tenofovir disoproxil fumarate) and Descovy (emtricitabine/tenofovir alafenamide), and their respective risks and benefits?

From the Guidelines

Pre-Exposure Prophylaxis (PrEP) is highly effective in preventing HIV infection when taken as prescribed, with Truvada and Descovy being the primary options, each with their own set of risks and benefits. The choice between Truvada (emtricitabine 200mg/tenofovir disoproxil fumarate 300mg) and Descovy (emtricitabine 200mg/tenofovir alafenamide 25mg) should be based on individual factors including anatomy, cost considerations, and potential side effect profiles 1.

Key Differences and Recommendations

• Truvada is FDA-approved for all populations and may cause mild initial side effects like nausea or headache, potentially affecting kidney function and bone mineral density with long-term use.
• Descovy has less impact on kidneys and bones but may cause slightly more weight gain and cholesterol changes, and is approved for men who have sex with men and transgender women but not for those at risk through receptive vaginal sex.
• Generic versions of Truvada offer the same protection at lower cost.
• All PrEP medications require HIV testing before starting and every 3 months thereafter, along with kidney function monitoring and STI screening 1.

Monitoring and Follow-Up

• Quarterly monitoring includes combined HIV antibody and antigen test, estimated creatinine clearance rate, and genital and nongenital gonorrhea and chlamydia testing by NAAT 1.
• Annual monitoring includes combined HIV antibody and antigen test, estimated creatinine clearance rate, and hepatitis C virus antibody test for certain populations 1.

Special Considerations

• Individuals with osteopenia or osteoporosis, or a creatinine clearance rate of less than 60 mL/min, should carefully weigh the risks and benefits of PrEP, with Descovy potentially being a better option due to its reduced impact on kidneys and bones 1.
• Transfeminine persons using exogenous estrogens or androgen blockers may require additional measures to support maximal adherence to daily dosing due to potential reductions in tenofovir/tenofovir metabolite concentrations 1.

From the FDA Drug Label

The most common adverse reactions (incidence greater than or equal to 10%, all grades) included diarrhea, nausea, fatigue, headache, dizziness, depression, insomnia, abnormal dreams, and rash. Table 4 provides the treatment-emergent adverse reactions (Grades 2 to 4) occurring in greater than or equal to 5% of subjects treated in any treatment group Emtricitabine + TDF + EFV: Fatigue 9%, Depression 9%, Nausea 9%, Diarrhea 9%, Dizziness 8%, Upper respiratory tract infections 8%, Sinusitis 8%, Rash event 7%, Headache 6%, Insomnia 5% Laboratory Abnormalities: Laboratory abnormalities observed in Trial 934 were generally consistent with those seen in previous trials (Table 5). Any ≥ Grade 3 Laboratory Abnormality 30%, Fasting Cholesterol (>240 mg/dL) 22%, Creatine Kinase(M: >990 U/L)(F: >845 U/L) 9%, Serum Amylase (>175 U/L) 8%

PreP Options and Risks/Benefits:

• Truvada (emtricitabine/tenofovir disoproxil fumarate):
  • Risks: Diarrhea, nausea, fatigue, headache, dizziness, depression, insomnia, abnormal dreams, rash
  • Benefits: Effective in preventing HIV-1 infection
• Descovy (emtricitabine/tenofovir alafenamide):
  • No direct information available in the provided drug labels
  • However, emtricitabine is a common component in both Truvada and Descovy, so similar risks may apply

Comparison of PreP Options:

• Both Truvada and Descovy contain emtricitabine, but the second component differs (tenofovir disoproxil fumarate in Truvada and tenofovir alafenamide in Descovy)
• The provided drug labels do not directly compare the risks and benefits of Truvada and Descovy
• More information would be needed to make a comprehensive comparison of the two PreP options 2, 2

From the Research

Pre-Exposure Prophylaxis (PreP) Options

• Truvada (emtricitabine/tenofovir disoproxil fumarate): a combination antiretroviral regimen taken as a single pill once daily, shown to prevent HIV transmission with an efficacy exceeding 90% when adhered to daily 3
• Descovy (emtricitabine/tenofovir alafenamide): an alternative to Truvada, with similar efficacy and safety profiles, but with potentially fewer side effects, particularly on kidney function 4

Risks and Benefits of PreP Options

• Truvada:
  • Benefits: highly effective in preventing HIV transmission, safe and well-tolerated, with fewer than 2% of people discontinuing due to adverse effects 3
  • Risks: potential for kidney damage and chronic kidney disease, increased risk of sexually transmitted infections, rare cases of resistance to the medication 3, 5, 6
• Descovy:
  • Benefits: potentially fewer side effects on kidney function compared to Truvada, similar efficacy in preventing HIV transmission 4
  • Risks: limited data on long-term use and potential adverse effects, high costs of the medication, stigma associated with PreP use 4

Comparison of PreP Options

• Both Truvada and Descovy are effective in preventing HIV transmission, but Descovy may have a more favorable safety profile, particularly with regards to kidney function 5, 6, 4
• Truvada has a longer history of use and more established safety and efficacy data, but Descovy may offer a more convenient and tolerable alternative for some individuals 3, 4
• The choice between Truvada and Descovy should be based on individual patient needs and preferences, as well as consideration of potential risks and benefits 7, 4