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Truvada on-demand (PreP)?

Mar 12, 2018

Hello, I have been on Truvada for 2 years and 3 months. I did lab tests every 90 to get my Truvada refill (HIV, Syphillis, Chlamydia, Comprehensive metabolic panel and Urinalysis). My doctor, recently told me that I can switch to on-demand Truvada since I am not at risk all the time. Every couple of months, I engage in reckless behavior for about a week at a time. And then a month long vacation once year. In summary, one week every 2 months and 30 days once a year. A couple days ago, I decided to stop by daily dose of Truvada based on my doctor's recommended other option (on-demand) even though the CDC doesn't really recommend it. A French study showed that on-demad Truvada can also be quite effective. I have enough supply of Truvada to literally last me 3 years because because of the on-demand switch, and I will continue to do the STD tests for my own piece of mind every once in a while although not every 90 days like I used to do. The only reason I did those tests every 90 days was because they were a prerequisite for my refill of the meds.

My question: how often should I do the liver and kidney tests now that I am not taking Truvada every day? Thank you.

Response from Mr. Jacobs

Hi there -- Congrats on making an informed and educated decision about your sexual health. It is refreshing to hear about an American medical doctor who learns and respects medicine and science as it is practiced outside the U.S. Unfortunately, the CDC is lagging far behind the research on this one, and has yet to come out in favor of on-demand PrEP dosing as a viable option.

So for those who want a catch up here: There is a PrEP "on-demand" regimen that seems to prevent HIV for anal sex just as effectively as daily IF someone is not regularly sexually active. It entails using 2 doses of Truvada anywhere from 2-24 hours before a sexual event, then one dose 24 hours after the sexual event, and another dose another 24 hours after that. All together, that is 4 doses per sexual event. If you are having more sex for a consistent period (like on a vacation or isolated period), then you keep using daily and then cease when you are no longer sexually active (one 24 hours later, another dose 24 hours after that).

There has yet to be a single seroconversion reported with the on-demand dosing regimen when it is taken exactly as prescribed (http://www.thebody.com/content/77432/can-prep-dosing-for-anal-sex-be-event-driven-inste.html ; http://www.aidsmap.com/Ipergay-trial-PrEP-still-protected-people-who-had-less-sex-and-used-it-less-often/page/3159786/). However, it is important to keep in mind that this is only indicated for men who have sex with men and trans women for rectal sex. It has not been studied in heterosexual men, women, trans men, or people who inject drugs -- there is simply no evidence available that it would work for these groups.

Some people prefer this schedule, as you pointed out, because it simply makes sense to take a drug when you truly need it, as well as for insurance/cost benefits.

Now to get to your question -- your doctor will be following up with you and primarily watching your kidney functioning. Truvada is not processed by the liver (http://www.thebody.com/content/80188/prep-and-lactic-acidosis-warnings-context-matters.html).

How often would you be advised to have your kidneys checked if you are just using it for these events? There is no protocol or guidelines which medically answer this question. What we do know is that the CDC recommends kidney tests every six months for daily use of Truvada. We know some doctors are ordering more than that, some doctors prefer to monitor kidney functioning every 3-4 months. We also now know that kidney changes with PrEP use are extremely rare, and constant monitoring for someone under the age of 40 is not really necessary (http://betablog.org/new-research-at-croi-2016-how-prep-changes-kidney-function/).

With that in mind, I'd say it's really going to be up to you and your doctor to determine the frequency of your tests. I don't know how old you are, but I would encourage you, even with on-demand dosing, to consider getting your kidneys checked at least once a year. Your doctor may order a comprehensive metabolic panel at the same time, which will give them access to seeing ALL your levels, including liver, cholesterol, and many others. It is wise to have a baseline of these levels at any age, and often just good for peace of mind.

If cost is an issue, that you may explore if you're going to meet your insurance deductible or not (which you may not if you're not refilling Truvada this year). If you are going to reach you deductible, then getting your blood drawn will most likely cost less for you after that amount is met.

One thing to keep in mind however, you stated above engage in "reckless behavior" at times. What is reckless about protecting yourself while enjoying pleasure? You are making the most informed, science-based decision one could possibly make about HIV protection and sex. I invite you to consider shifting the thinking here more along the lines of, "I enjoy sex certain times of the month and I'm empowered and responsible enough to take care of myself while I'm having fun!"

I hope this helps you to make a clearer decision about your health and wellness. For more information about PrEP, on-demand dosing, kidney screenings and more, please join us the global Facebook group at: https://www.facebook.com/groups/PrEPFacts/



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