Descovy for HIV: Pre-Exposure Prophylaxis and Treatment
Descovy (emtricitabine/tenofovir alafenamide) is FDA-approved for HIV pre-exposure prophylaxis (PrEP) in specific populations, but it is NOT approved for PrEP in cisgender women or transgender men at risk through vaginal exposure. 1
Approved Indications for Descovy
PrEP Approval (Limited Population)
- Descovy is approved for PrEP only in cisgender men who have sex with men (MSM) and transgender women who have sex with men 2, 3
- The DISCOVER trial demonstrated non-inferiority to Truvada (TDF/FTC) for HIV prevention in MSM and transgender women, with an incidence rate ratio of 0.47 (95% CI 0.19-1.15) 3
- At 96 weeks, Descovy maintained efficacy with only 0.16 infections per 100 person-years compared to 0.30 with Truvada 4
Critical Limitation for PrEP Use
- Descovy is absolutely NOT recommended for cisgender women or transgender men at risk through vaginal exposure 1, 2, 5
- For females requiring PrEP, Truvada (TDF/FTC) remains the only approved and effective option with proven efficacy 5
- Descovy is also NOT recommended for event-driven "2-1-1" dosing 2
When to Choose Descovy Over Truvada for PrEP
Use Descovy as an alternative to Truvada specifically for MSM or transgender women with:
- Creatinine clearance 30-60 mL/min (Truvada requires ≥60 mL/min) 1, 2
- Osteopenia or osteoporosis 1, 2
- Age >50 years with renal risk factors 1
Safety Advantages of Descovy
- Superior bone mineral density outcomes compared to Truvada across all six prespecified endpoints 3
- Superior renal biomarker safety profile compared to Truvada 4, 3
- Well-tolerated with only 1% discontinuation rate due to adverse events 3
Important Caveat
- More weight gain observed with Descovy (median 1.7 kg vs 0.5 kg with Truvada at 96 weeks, p<0.0001) 4
Dosing and Administration
PrEP Dosing
- Descovy: emtricitabine 200 mg/tenofovir alafenamide 25 mg once daily 2
- Requires 1-week lead-in period before adequate tissue levels are achieved for rectal and penile exposures 2
- Continue for 1 week after the last sexual exposure when discontinuing 2
Pre-Initiation Requirements
Before starting Descovy for PrEP, obtain:
- Combined HIV antibody and antigen testing (if acute HIV suspected, add HIV RNA testing) 2
- Serum creatinine and estimated creatinine clearance (do not start if <30 mL/min for Descovy) 1, 2
- Hepatitis B surface antigen (HBsAg) 2
- Hepatitis C antibody 2
- Three-site STI screening (rectal, pharyngeal, urogenital) for gonorrhea and chlamydia by NAAT 2
- Pregnancy testing for individuals of childbearing potential 1
Ongoing Monitoring Schedule
Every 3 Months
- Combined HIV antibody and antigen testing 1, 2
- Three-site STI screening (rectal, pharyngeal, urogenital) for gonorrhea and chlamydia 1, 2
- Syphilis testing 1
- Pregnancy testing for individuals of childbearing potential 1
- Assessment of adherence and risk behaviors 1
Every 6-12 Months
- Serum creatinine and estimated glomerular filtration rate 1, 2
- More frequent renal monitoring (every 3-6 months) required for patients >50 years, taking hypertension/diabetes medications, or baseline eGFR <90 mL/min 2
Absolute Contraindications
Do not prescribe Descovy for PrEP if:
- HIV status is positive or unknown 1
- Creatinine clearance <30 mL/min 1
- Patient is a cisgender woman or transgender man at risk through vaginal exposure 1, 2, 5
- PrEP prescriptions should not exceed 90 days without interval HIV testing 1
Management of HIV Infection During PrEP
If HIV infection occurs while on Descovy:
- Immediately add a boosted protease inhibitor (darunavir/ritonavir or darunavir/cobicistat) and/or dolutegravir to the current regimen while awaiting HIV RNA and resistance testing 2
- Switch to a recommended initial antiretroviral regimen once HIV is confirmed 2
- Drug resistance when using PrEP is rare (<0.1%) and usually occurs when PrEP is inadvertently prescribed to individuals with undiagnosed acute HIV infection 6