Descovy: Everything You Need to Know

Descovy is a combination medication (tenofovir alafenamide/emtricitabine) considered to be the younger, sexier, and potentially safer sibling of Truvada (tenofovir disoproxil fumarate/emtricitabine) that is used for both HIV treatment and prevention. The emtricitabine (FTC) component of Descovy has been on the market since 2003, but tenofovir alafenamide (TAF) was only recently approved by the Food and Drug Administration (FDA): first, to be part of Descovy as part of a combination HIV treatment regimen, in 2016, then later as part of Descovy alone for HIV prevention, in 2019.

TAF and FTC have quickly emerged as a staple of several of the initial combination antiretroviral treatment (ART) regimens recommended by the Department of Health and Human Services (HHS) Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV. TAF and FTC are also featured in a multitude of single-tablet regimens (STR), such as Genvoya, Odefsey, Symtuza, and Biktarvy. Descovy is used in combination with other integrase inhibitors (e.g., Tivicay [dolutegravir] and Isentress [raltegravir]) and sometimes members of other drug classes (e.g., protease inhibitors or NNRTIs). Because TAF has been found to be significantly less impactful on markers of long-term kidney and bone health, many have been turning to TAF as an essential part of their ART regimen instead of tenofovir disoproxil fumarate (TDF), a component of Truvada and older single-tablet regimens for HIV treatment.

One of the benefits of including TAF as part of an initial or continued ART regimen is that not only is it effective in slowing down HIV, it is also useful in the treatment of hepatitis B, similar to TDF. Both FTC and TAF are effective against hepatitis B, with FTC being considered not as strong of a treatment due to problems with resistance. TAF is a little more durable and less prone to resistance for the treatment of hepatitis B, so the two combined as part of a complete ART plan is a no-brainer if you are also living with chronic, active hepatitis B. Essentially, Descovy is good for treating both viruses.

What’s the Main Difference Between Descovy and Truvada?

Both TDF and TAF are prodrugs of tenofovir diphosphate, the active form that gets into T cells to slow down HIV replication. Studies have shown that TAF produces higher levels of this active drug in T cells with smaller doses than TDF, thus leading to lower drug levels in the bloodstream and potentially less toxicity to the kidneys, bones, and other organs.

This is important, because for people living with kidney disease or impaired kidney function, Truvada was not considered an option by them or their clinicians due to concern over making things worse. Descovy is more forgiving in this respect and has been approved for HIV treatment and prevention even for individuals with mild renal impairment, given its safer kidney profile. Additionally, Descovy boasts a smaller pill size than its older sibling, Truvada, which makes it more desirable for the many people who have trouble with larger-sized pills. In this case, smaller is better.

How to Take Descovy

Descovy, whether taken for treatment or as PrEP, is FDA-approved in the United States to be taken once daily, with or without food. Food does not impact absorption of either medication, but some may find that taking Descovy with food is easier on the stomach. Unlike Truvada, Descovy is not yet approved to be taken as PrEP in an “on demand” fashion, where people can take two tablets between two and 24 hours before sex, then another pill 24 hours after the first two, and another pill 48 hours after the first two. The assumption among some medical providers is that Descovy may also be effective as PrEP when taken on demand, but there is no literature to support this alternative dosing strategy as of yet.

Regimens containing TAF, including Descovy, have not been specifically studied for HIV post-exposure prophylaxis (PEP) and are therefore not currently recommended as a component of PEP.

How Much Does Descovy Cost?

Descovy contains 25 mg TAF and 200 mg FTC, much lower than the 300/200 mg dose of Truvada, due to the TAF component taking a more direct journey to T cells than TDF does. As the newer, smaller, and safer version of Truvada, Descovy won’t likely be available in a generic version until at least 2026, so its cost is approximated to be about $2,000 for a month’s supply, comparable to Truvada. This can obviously be a deterrent when considering Descovy for HIV treatment, but it really hits people’s pockets if they are considering it for HIV prevention and they may not be convinced that they need to take a pill daily for HIV prevention.

Similar to Truvada, if you have insurance, monthly copays for Descovy can typically run between $10 and $50, depending on the plan, though some plans may waive both deductibles and copays associated with Descovy for PrEP due to coverage requirements for certain preventive health services under the Affordable Care Act (ACA). If you don’t have insurance or your insurance won’t cover the majority of Descovy’s cost (you are “underinsured”), the same patient assistance program used for Truvada can help reduce the cost to as little as no copay, depending on meeting certain requirements.

Side Effects of Descovy

Descovy has been demonstrated to be a safer alternative to Truvada for both HIV prevention and treatment, particularly when it comes to bone and kidney health. Results from the DISCOVER trial at the 96 week mark found that when compared with Truvada for PrEP, it was no less effective in reducing risk of HIV transmission, it had less negative impact on markers of kidney and bone health, and participants had stable cholesterol levels.

Reports have emerged about increased cholesterol medication usage and weight gain among people using Descovy for PrEP, which has created controversy over whether an automatic switch to Descovy for patients currently on Truvada is warranted. In other words, just because we have a shiny new medication in the toolbox for HIV prevention and treatment doesn’t necessarily mean it should be the first choice for everyone. In addition to checking kidney function, providers will also have to monitor patients for weight gain and any concerning cholesterol changes.

If you are currently taking Descovy for PrEP or treatment, it is likely that your medical team will be having you come in to check for labs every four to six months. That’s the best way to stay on top of things.

Descovy and Other Drug Interactions

While the potential for kidney damage with Descovy is less than Truvada, it is still recommended to be careful if you are on any other medications that could harm the kidneys: anti-inflammatories, some antibiotics, and blood pressure meds. Make sure to review any other prescription, over-the-counter, or holistic medications you may be taking with your medical providers. Seizure medications like Tegretol (carbamazepine), phenobarbital, and Dilantin (phenytoin) all can decrease TAF concentration in the bloodstream, so if you do have a seizure disorder, discuss alternative medications with your medical provider when on Descovy.

Similarly, medications used to treat tuberculosis like rifampin and rifabutin, as well as the herbal medication St. John’s wort, can all reduce TAF concentrations as well, making Descovy less effective for both HIV prevention and treatment.

If you are transgender or gender nonbinary and taking estrogen, previous studies demonstrated that estrogen can reduce the concentration of TDF in the bloodstream when taking Truvada for PrEP. However, in the DISCOVER trial, no significant changes in TDF or TAF were noted in the transgender women who were on high-dose hormone therapy. To date, no studies have found that Descovy or Truvada reduces the concentrations of estrogen or other hormone therapy. For transgender women who are on estrogen, not to worry—you can utilize Descovy for PrEP without worry of drug interactions causing any interference with your gender-affirming hormones.

Descovy as HIV Treatment

Descovy and its components have become a primary option for HIV treatment since its approval in 2016, whether combined separately with other medications or as part of an STR. It has truly been a cultural shift, as most providers who had their patients on a Truvada-based regimen immediately began switching patients to a Descovy-based combination when it became available.

The ADVANCE trial examined the effectiveness of Tivicay (dolutegravir, an integrase inhibitor) in combination with either Descovy or Truvada for treating individuals living with HIV. They found that the combinations were both equally as effective as other standard ART regimens in terms of viral suppression. However, they also found a significant amount of weight gain with these Tivicay-based regimens, and even more so when combined with Descovy instead of Truvada.

This is important because much of the weight gain seen in this study and others is in what’s called “truncal obesity,” increasing weight and fat collections around the waist, which is known to be a predictor of heart disease and cardiovascular mortality. In essence, these findings must be considered when thinking about ART regimens for an increasingly aging HIV population. What initially looks like a safer drug in terms of kidney and bone disease may not be as safe when it comes to weight gain, cholesterol, and cardiovascular health. While it may be too early to tell and make sweeping generalizations, what is clear is that conversations about switching from a Truvada-based ART regimen to one that is Descovy-based may not be as simple as we originally thought.

Pre-Exposure Prophylaxis (PrEP)

When it comes to protection against HIV, Descovy is very effective, showing a 99.7% reduction in risk compared with 99.4% with Truvada. The true good news about this is that, given a better side effect profile when it comes to kidney and bone health, Descovy presents a great one-pill-a-day option for HIV prevention. In the DISCOVER trial that compared Descovy to Truvada, researchers found that in participants older than 50, Descovy had less renal impairment when looking at several different markers. Similar favorable profiles with bone health existed for participants under the age of 25 in the same study.

Worsening kidney function occurs with older age and when people have other conditions like diabetes and high blood pressure. For individuals over the age of 50 who may have impaired kidney function or concern about kidney damage, Descovy should be a consideration as an option for HIV prevention over Truvada. For those younger than 25, when you want to make sure that your relatively younger bones have the opportunity to grow and be strong, Descovy could be a suitable option for you, particularly if you have asthma or an autoimmune disease and are also on prednisone, a medication known for causing bone thinning with long-term use.

Just like Truvada, Descovy is a good combination medication for treatment/coverage of hepatitis B for someone who is not living with HIV as well. There have been reports, however, of patients experiencing an acute flare of hepatitis B (abdominal pain, liver swelling, nausea, and vomiting) when the medication is stopped suddenly. Care must be taken, knowing that for people taking Descovy, this could happen if it is stopped abruptly. For those people taking Descovy as a part of HIV treatment, this may not be an issue, as there is incentive to continue medications for HIV viral suppression. For PrEP, however, when you are HIV negative and are taking Descovy as a preventive measure, the likelihood of stopping at some point is greater. So care is always advised if you are taking Descovy as HIV PrEP and you are also living with chronic, active hepatitis B.

An important consideration with the DISCOVER trial that confirmed Descovy as an effective option for HIV prevention involves the study population. Not only were there few Black and Latinx individuals represented in the study sample, but there were notably no cisgender women participants: The population studied were men who have sex with men (MSM) and transgender women (TGW).

Thus, when the FDA approved Descovy for PrEP in October 2019, it came with the restriction that it was to be used for HIV prevention only with MSM and TGW, but not for anyone engaging in “receptive vaginal sex.” This is problematic, for sure, but the FDA approval indication was appropriate, as studies have shown that for the active form of both TDF and TAF, tenofovir diphosphate, therapeutic drug levels in the blood may not always translate to therapeutic levels in vaginal tissue. Stating that Descovy would be effective during receptive vaginal sex would be a false statement given that only MSM and TGW were in the study sample.

What’s the Verdict on Descovy?

After four years being a part of ART regimens and close to a year of being approved as a PrEP alternative, the verdict is somewhat mixed on Descovy. With regard to outcomes of viral suppression if you are living with HIV or prevention if you are HIV negative, the data is overwhelming in support of its effectiveness. If you are looking for a safer treatment or prevention alternative to Truvada when it comes to kidney and/or bone health, Descovy is a great option. These are the pros.

When it comes to cons, we start with the limits on the indication for PrEP. If you are a cisgender woman engaging in receptive vaginal sex, the data is just not out yet to suggest that Descovy works as well for HIV prevention as it does with MSM or TGW. Given that 19% of new U.S. HIV diagnoses in 2018 were among cisgender women, and 57% of those cases were in Black women, this is disappointing. Thus, in 2020, Truvada is still the only FDA-approved option for PrEP to which cisgender women can turn.

The other notable con with Descovy concerns its side effect profile. Yes, studies have confirmed that there is less bone loss and impact on markers of kidney health with Descovy compared with Truvada, but the issue of weight gain has gained increased prominence as a concerning side effect in both HIV treatment and prevention studies. To be clear, the weight gain is not simply a cosmetic issue, but also a general health concern, as the notable truncal obesity associated with Descovy could have clinical significance for older persons who are struggling with other conditions like high blood pressure, diabetes, and high cholesterol—all of which can have a negative impact on one’s cardiovascular health.

What this means is that when it comes to HIV prevention and treatment options, the battle of Truvada versus Descovy is not as simple as it originally appeared. Yes, Descovy is a smaller pill than Truvada. Yes, it is a better medication if you are concerned about potential kidney and bone side effects. But if you have risk factors for cardiovascular disease and are trying to manage or reduce that risk, either switching to Descovy as part of your ART regimen or choosing Descovy for HIV prevention may involve a more in-depth conversation with your medical provider.

Looking at the big picture, Truvada is still a very safe and effective medication, both for HIV treatment and prevention. With its patent due to expire soon, issues of cost and insurance coverage, in addition to consideration of potential side effects, will surely play a role in which of these rival sibling medications you choose for your overall and sexual health. Just remember that the grass isn’t always greener on the other side.