Can Truvada Prevent HIV If Taken Only As Needed?

Event-Driven Prophylaxis (ED-PrEP) with Truvada is effective, but it’s not for everyone.

Truvada is unquestionably one of the best tools for stopping the spread of HIV.

According to the CDC, Truvada is about 99% effective when a person tightly adheres to the daily regimen.

But many for men who have sex with another man only occasionally and can plan ahead, daily dosing may not be necessary. This can be a real advantage for older men, especially those with other medical conditions.

Prescribing Truvada typically falls out of the scope of practice of psychiatrists, so when a correspondent asked me a question about it, I consulted with some doctors who are experts.

Some men do not need to take Truvada daily.

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In July 2019, The World Health Organization (WHO) published an update to their earlier recommendations on the use of Pre-Exposure Prophylaxis(PrEP) to prevent HIV for men who have sex with men.

The alternative treatment protocol is called ED-PrEP or 2 + 1 + 1.

2 + 1 +1 = ED-PrEP

ED-PrEP has proven highly effective in reducing HIV for men who have sex with men (MSM) but only occasionally and predictably and who engage in either receptive or insertive anal intercourse.

Why is ED-PrEP also called 2 + 1 + 1?

ED-PrEP for MSM consists of taking a two-pill loading dose 24 hours before sex; then another one pill is taken 24 hours later; a final, fourth pill is taken an additional 24 hours later. 2 + 1 + 1

The effectiveness of other regimens, such as taking a single pill before sex or taking PrEP four times per week, is unknown.

When should I use daily PrEP and when ED-PrEP?

WHO does not recommend ED-PrEP for MSM who have sex more than twice a week or when sex cannot be predicted or delayed for two hours.

All people at risk for HIV because of frequent sex or when they are unable to predict when they will have sex should take Truvada daily.

A man can stop daily PrEP when he stops having sex.

An MSM on daily PrEP can switch to ED-PrEP if he begins to have only occasional and predictable sex. Those on ED-PrEP can move back to daily dosing to stay protected if their sexual activity increases.

Whether on daily PrEP or ED-PrEP, regular HIV testing and other lab tests should be the same for all users of both treatment regiments. These men should have follow-up visits one month after initiating the treatment and every three months to:

  • Provide testing for HIV and other sexually transmitted diseases (STDs)
  • Offer to counsel about adherence to dosing strategy and transitioning from one form of treatment to the other.
  • Assess if HIV risk is likely to persist into the next weeks and months

Who should use ED-PrEP, and who should not?

The preference for ED-PrEP over daily dosing depends on the MSM’s risk profile. Daily dosing is considered by many to be easier to use, but ED-PrEP can be an attractive alternative for MSM who do not wish to be on the daily dosing of PrEP.

Men who have only occasional sex, those who can plan their sexual activities, and those who are older sometimes prefer ED-PrEP.

ED-PrEP is a particularly good option for older men who have other medical issues (such as kidney problems) that can be exacerbated by regular use of PrEP.

Experts do not recommend ED-PrEP for the following because of insufficient evidence:

  • Women
  • Transgender women and men who have vaginal or anal intercourse with women
  • 2 + 1 + 1 is not recommended for men less than 18-years-old. Adolescent men may require more active support.

Some resist the daily PrEP dosing because of concerns about the long-term consequences of taking a daily dose of Truvada; others may oppose it because of the expense. (Daily dosing can cost upwards of $1500 per month if paid out-of-pocket.)

Experts do not recommend ED-PrEP at this time for Descovy because data are not yet available.

Risks and Benefits of ED-PrEP

Potential benefits of ED-PrEP:

  • It provides choice and convenience
  • Gives men who can anticipate, plan or delay sex an option
  • Reduces the burden of taking a daily pill
  • Saves costs

Potential risks of ED-PrEP:

  • May be difficult for some, e.g., adolescents.
  • The possible emergence of HIV drug resistance
  • Since ED-PrEP is a dosing option only for MSM, a person who is unable to declare his sexual orientation openly could experience unintended consequences of monitoring. ED-PrEP could occur in countries that criminalize same-sex activity.

The WHO update recommends regular education and support for both ED-PrEP and daily dosing of PrEP.

Is it safe?

Truvada is unquestionably one of the best tools for stopping the spread of HIV.

Research shows ED-PrEP offers significant protection against HIV with proper usage. Although the daily dose of PrEP is nearly 100% effective, a few case failures have been reported.

According to a single report, one individual seroconverted (switched from HIV- to HIV+) on ED-PrEP.

Some disagreement remains among doctors and researches, but the experts I consulted recommend 2 + 1 +1 when following the above guidelines.

For those with no insurance and limited means, ED-PrEP is undoubtedly a better option than no treatment.

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Gay father; Psychiatrist; Award-winning author FINALLY OUT. Chapter excerpt here: Top writer on Medium. Not medical advice.

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