Change prep because of Truvada's bone issues?

Question

A recent trip to the NIH for a check-up generated the following suggestion from my providers - get off of Truvada because it can cause/exacerbate bone density issues. I am a very rare case - 40th year HIV pos and have had osteo-issues in the past that are not now an issue. I am undetectable and cd4 of 250. Should we be suggesting a drug that causes bone issues to treatment naiive people taking prep rather than another antiviral that offers protection w/o the bone issues?

Answer

Hi there --

When I first read the title of your question, I thought you were referring to "PrEP" - which stands for pre-exposure prophylaxis. PrEP is a daily pill that prevents HIV in persons who are HIV negative. At this time, Truvada is the only drug approved for use of PrEP, and so we often use "Truvada" and "PrEP" interchangeably. Truvada is also part of a drug combination that is used by people living with HIV to suppress their virus, and become undetectable. The key difference here is that someone living with HIV would need to take Truvada with other drugs for treatment, whereas someone on PrEP would be taking Truvada by itself for prevention.

These are important distinctions when we talk about the issue of bone density. As you point out Truvada, as part of treatment, has been known to cause/exacerbate bone density issue. For that reason, Descovy is a newer drug that is now often being recommeded. Descovy is very similar to Truvada in its ability to suppress an HIV viral load when used in combination with other medications. However, Descovy has significantly less side effects, less impact on bone density, and is therefore now being recommended for treatment by many prescribers instead of Truvada (http://www.thebody.com/content/77389/descovy-new-hiv-drug-containing-tenofovir-alafenam.html).

For prevention, however, it's a very different story. Bone density issues in HIV negative people using Truvada for prevention are exceedingly rare, and are ultimately reversed if the person stops using the drug (https://aidsinfo.nih.gov/news/1653/nih-funded-study-finds-effect-of-prep-on-bone-density-is-reversible). It is unknown if Descovy works as well as Truvada to prevent HIV, but there is currently a trial seeking to find these answer. The study itself, has been fraught with controversy and concerns by many activists and organizations (http://www.thebody.com/content/78797/why-are-hiv-groups-charging-gilead-with-bad-behavi.html).

Ultimately, whatever treatment or prevention strategies are used exist between a patient and their provider. But it is important everyone understands their options, risks, and benefits .

Thank you for a great question, and much congrats on taking such exquisite care of yourself. 40 years living with HIV is a monumental accomplishment and deserving of incredible respect.