Is Descovy (emtricitabine and tenofovir alafenamide) required for HIV pre-exposure prophylaxis (PrEP) in a monogamous relationship where both partners are HIV-negative?

Is Descovy Required in a Monogamous Relationship?

Descovy (or any PrEP) is not required in a truly monogamous relationship where both partners are confirmed HIV-negative, but the critical clinical challenge is verifying both the HIV status and the actual monogamy of the relationship.

When PrEP is NOT Required

PrEP can be reasonably deferred for HIV-negative individuals in monogamous relationships with HIV-negative partners 1. However, this decision requires:

• Documented negative HIV testing for both partners using combination antigen-antibody assays 1
• Confirmed mutual monogamy with no outside sexual partners 1
• No injection drug use with shared equipment 1

The Hidden Risk: Why This Question is Deceptive

The evidence reveals a sobering reality about perceived monogamy versus actual risk:

• 66% of HIV-positive women in one study reported having only one sexual partner before their HIV diagnosis 2
• Over 90% had no knowledge of their partner's HIV-positive status or bisexual orientation 2
• 64% had sex ≥4 times with the partner from whom they acquired HIV 2
• Transmission can occur when an HIV-seronegative partner in a serodiscordant relationship has partners outside of that relationship 1

This data demonstrates that self-reported monogamy is an unreliable predictor of actual HIV risk, particularly for heterosexual women.

When PrEP IS Recommended in "Monogamous" Relationships

PrEP is specifically recommended for HIV-seronegative partners of HIV-infected persons who are not consistently virally suppressed 1. The guidelines define "not consistently virally suppressed" as:

• Viral load >200 copies/mL 1
• Less than 6 months of documented viral suppression 1
• Inability to document durable viral suppression 1

For partners of people living with HIV who ARE virally suppressed (<200 copies/mL) on ART, it is reasonable to defer PrEP, but it is also reasonable to provide it if requested because of the possibility of undisclosed exposures 1.

The Serostatus-Neutral Approach

Current 2024 guidelines recommend a paradigm shift:

• Offer PrEP to all sexually active individuals, anyone requesting it, without specific risk criteria or screening tools 1
• This approach reduces HIV stigma and acknowledges that traditional risk assessment tools fail to identify many individuals who subsequently acquire HIV 1, 2

Practical Clinical Algorithm

Step 1: Verify HIV Status

• Both partners need documented negative HIV testing within the past 7 days using combination antigen-antibody assays 1
• If one partner is HIV-positive, proceed to Step 2

Step 2: Assess Viral Suppression (if applicable)

• If HIV-positive partner has viral load <200 copies/mL for ≥6 months on ART: PrEP can be deferred but should be offered if requested 1
• If HIV-positive partner is NOT virally suppressed: PrEP is recommended 1

Step 3: Assess Actual Monogamy Risk

• Do not rely solely on patient self-report of monogamy 2
• Ask specifically about:
  • Partner's HIV status and testing history
  • Partner's sexual orientation and other partners
  • Partner's injection drug use
  • Patient's own outside partners (normalize this question)

Step 4: Patient Preference

• If the patient requests PrEP, provide it 1
• The 2024 guidelines explicitly state this is reasonable even in low-risk scenarios because of undisclosed exposures 1

Regarding Descovy Specifically

Descovy (emtricitabine/tenofovir alafenamide or F/TAF) has important limitations:

• F/TAF is NOT recommended for individuals whose exposures include receptive vaginal sex 3
• F/TAF should be limited to cisgender men and others whose exposures do not include receptive vaginal sex 3
• For women requiring PrEP, tenofovir disoproxil fumarate/emtricitabine (TDF/FTC, generic Truvada) remains the only recommended option 4, 3
• Daily dosing is especially critical for women because tenofovir concentrates at 10-fold lower levels in vaginal tissue than rectal tissue 1, 4

F/TAF may be preferred for cisgender men and transgender women with:

• Creatinine clearance 30-60 mL/min 1
• History of osteopenia or osteoporosis 1
• High risk for bone or renal complications 1

Common Pitfalls to Avoid

1. Accepting self-reported monogamy at face value - 66% of women who acquired HIV reported having only one partner 2

2. Prescribing Descovy to women - It lacks efficacy data for vaginal exposures 3

3. Assuming viral suppression equals zero risk without documentation - Requires ≥6 months of documented suppression 1

4. Failing to offer PrEP when requested - Current guidelines support patient autonomy in PrEP decisions 1

Bottom Line

In a verified monogamous relationship with two confirmed HIV-negative partners, PrEP is not medically necessary. However, the clinical reality is that verifying true monogamy is nearly impossible, and many individuals who believe they are in monogamous relationships are actually at substantial risk 2. The safest approach is to offer PrEP to anyone who requests it, regardless of their reported relationship status 1.