What are the guidelines for transitioning a patient from Truvada (emtricitabine/tenofovir disoproxil fumarate) to Apretude (cabotegravir) for Pre-Exposure Prophylaxis (PREP)?

Transitioning from Truvada to Apretude for PrEP: Patient Education and Management

The recommended protocol for transitioning from oral Truvada (emtricitabine/tenofovir disoproxil fumarate) to Apretude (cabotegravir) for PrEP requires continuing oral Truvada for 7 days after the first cabotegravir injection to ensure continuous HIV protection during the transition period. 1

Pre-Transition Assessment

• Confirm HIV-negative status with both rapid point-of-care HIV antibody test AND laboratory-based HIV antigen/antibody test before starting Apretude 2, 1
• If any symptoms of acute HIV infection are present, perform HIV RNA testing and delay transition until confirmed negative 2
• Assess renal function (creatinine clearance ≥60 mL/min) 2
• Screen for hepatitis B infection (cabotegravir does not treat hepatitis B, unlike Truvada) 2
• Complete STI screening (gonorrhea, chlamydia, syphilis) 2
• Assess for any contraindications to cabotegravir:
  • History of hypersensitivity to cabotegravir
  • Concomitant medications that may interact (carbamazepine, oxcarbazepine, phenobarbital, phenytoin, rifampin, rifapentine) 3

Transition Protocol

Step 1: Optional Oral Lead-In

• An oral cabotegravir (Vocabria) lead-in of approximately 1 month (at least 28 days) is optional but recommended for:
  • Patients with severe atopic histories
  • Patients who specifically request to test tolerability 1
• Oral lead-in is NOT recommended for patients who struggle with daily oral medication adherence 1

Step 2: First Injection and Overlap Period

• Schedule the first Apretude injection (600 mg/3 mL administered via gluteal intramuscular injection) 1
• Continue Truvada for 7 days after the first cabotegravir injection to maintain continuous protection 1
• Second injection should be scheduled 4 weeks after the first injection 1

Step 3: Maintenance Dosing

• After the first two injections (4 weeks apart), continue with injections every 8 weeks 1
• Provide a 1-month supply of Truvada as backup for use if injections are delayed by ≥7 days 1

Ongoing Monitoring

• HIV testing at each injection visit:
  • Rapid point-of-care HIV antibody test on the day of injection
  • Laboratory-based HIV antigen/antibody test (can be sent but don't delay injection pending results) 2, 1
• STI screening every 4 months (every second injection) 1
• Liver function tests every 6 months 1
• Assess for and manage injection site reactions with topical/systemic analgesics and hot/cold packs 1

Managing Missed Appointments

• If a patient will miss a scheduled injection by more than 7 days but less than 8 weeks:
  • Use daily oral PrEP (Truvada) until the injection can be administered 1
• If injections are resumed ≥8 weeks late:
  • "Reload" with two injections 4 weeks apart before returning to the 8-week schedule 1

Patient Education Points

1. Efficacy: Apretude has demonstrated superior efficacy compared to daily oral Truvada in preventing HIV acquisition 4

2. Convenience: Injections every 8 weeks after initial loading doses versus daily oral medication 5

3. Adherence: Eliminates daily adherence challenges but requires keeping injection appointments 6

4. Side Effects:

   • Common: Injection site reactions (pain, tenderness, swelling)
   • Less common: Headache, fever, fatigue, back pain
   • No kidney function concerns (unlike Truvada) 4

5. Transition period: Importance of taking Truvada for 7 days after first injection 1

6. Backup plan: What to do if an injection appointment is missed 1

7. Continued need for safer sex practices: Apretude does not protect against other STIs 3

Special Considerations

• For patients with gluteal implants or fillers, use caution with injection placement 1
• If a patient decides to discontinue Apretude but still needs HIV protection, transition back to oral PrEP 1, 7
• Cabotegravir may persist in the body for up to 12 months after the last injection, so continued monitoring is important even after discontinuation 7

Apretude represents a significant advancement in PrEP options with its long-acting formulation and superior efficacy compared to daily oral regimens, making it particularly valuable for individuals who struggle with daily medication adherence 4, 6.