The Ultimate HIV PrEP Showdown—Truvada vs. Descovy—A Doctor’s Guide

As a physician at PridePoint Health, one of the most common questions I get from patients interested in HIV prevention is: “What’s the difference between Truvada and Descovy, and which one is right for me?” Both are effective options for pre-exposure prophylaxis (PrEP), but there are important differences in their approved uses, side effects, and costs that are worth considering when making a decision.

In this article, I’ll break down the key differences between Truvada and Descovy to help you make an informed choice about which PrEP option is best for your individual needs.

A Brief Overview of Truvada and Descovy

• Truvada

  • Truvada was the first medication approved for PrEP in 2012. It contains two antiretroviral drugs: tenofovir disoproxil fumarate (TDF) and emtricitabine (FTC). Truvada has been a game-changer in preventing HIV, and it’s approved for a broad range of people, including cisgender women, men who have sex with men (MSM), transgender individuals, and people who are at risk through injection drug use. In my practice, Truvada is often the go-to option because of its long history and effectiveness across different populations.

• Descovy

  • Descovy was approved for PrEP in 2019 and is made up of a newer formulation of tenofovir called tenofovir alafenamide (TAF), along with emtricitabine (FTC). It was designed to reduce some of the risks seen with Truvada, particularly concerning kidney function and bone health. Descovy has been studied and approved for use in those at risk of sexually acquiring HIV, though does not include those who have receptive vaginal intercourse. It is also not approved for individuals at risk through injection drug use.

Key Differences: Who Can Use Them?

One of the first questions I ask patients is about their sexual practices and their risk factors for HIV. The biggest distinction between Truvada and Descovy is who can use them safely and effectively.

• Truvada:

  • Truvada is approved for a wide range of individuals, including people at risk of HIV from both vaginal and anal sex as well as injection drug use. This makes it the choice for cisgender women or people who have receptive vaginal intercourse. In my practice, I tend to prescribe Truvada for those who may need protection across various types of HIV exposure.

• Descovy:

  • Descovy is approved for folks at risk of sexually acquiring HIV, though does not include those who have receptive vaginal intercourse. If there are medical concerns regarding kidney or bone health, then Descovy might be a good fit. Descovy is not approved for those at risk for HIV through injection drug use.

Side Effects: What Studies Have Shown About Kidney and Bone Health

A lot of patients ask me about side effects, especially when it comes to long-term medication use. Here’s where we see some important differences between Truvada and Descovy.

• Truvada (TDF/FTC)

  • Kidney Function: Truvada has been associated, in rare cases, with a decline in kidney function over time, especially in individuals with pre-existing kidney conditions. The tenofovir disoproxil fumarate (TDF) in Truvada can lead to a loss of kidney function, though this is rare in individuals with healthy kidneys. In my practice, I monitor patients who are on Truvada long-term for any changes in kidney function, especially if they have underlying health conditions.

  • Bone Health: Studies have shown that Truvada can lead to mild but noticeable reductions in bone mineral density. This loss tends to stabilize over time, but it can be a concern for people who are already at risk for bone-related issues like osteoporosis.

  • The Studies: In the iPrEx study, less than 1% of participants taking Truvada experienced significant declines in kidney function. This was more pronounced in patients with pre-existing kidney disease or those over the age of 40 years old. For most healthy individuals, this reduction in kidney function was mild and reversible after discontinuing or changing from Truvada. The iPrEx study also found that up to 1.5% of participants experienced a small, but noticeable decline in bone mineral density after one year of Truvada use. On average, the decrease in BMD was around 1% to 2%, with most of the bone loss occurring within the first 6 months of use, then stabilizing over time. This is considered ‘subclinical’ as the decline isn’t substantial enough to cause health issues in otherwise healthy individuals.

• Descovy (TAF/FTC)

  • Kidney and Bone Health: Descovy was specifically designed to reduce the impact on kidney and bone health. The tenofovir alafenamide (TAF) in Descovy is delivered more efficiently to the cells, allowing for a lower dosage and reduced strain on the kidneys and bones. In clinical trials, patients taking Descovy experienced less decline in kidney function and bone mineral density compared to those on Truvada. This is a big reason why I might recommend Descovy to patients who have pre-existing conditions affecting their kidneys or bones.

  • Weight gain and Cardiovascular Risks: While Descovy is gentler on the kidneys and bones, there is emerging evidence suggesting it may be associated with increased cardiovascular risks. Some studies have indicated a slight increase in cholesterol levels and other markers of cardiovascular disease in patients taking Descovy compared to those on Truvada. This could be a concern for individuals with pre-existing heart conditions or those at higher risk for cardiovascular disease.

  • The Studies: The DISCOVER trial compared Truvada and Descovy and found that while Descovy had less impact on kidney function and bone health, it also led to slightly higher levels of weight gain (average +2.4 lbs vs -0.9 lbs for Truvada) and other components of metabolic health, such as LDL cholesterol and triglycerides. This could raise the risk of cardiovascular disease, particularly in individuals with pre-existing heart conditions or those at higher risk for cardiovascular issues.

Cost and Insurance Coverage

Cost is a common concern for my patients, especially when comparing these two medications. Here’s a look at how the costs compare—especially now that Truvada has a generic version.

• Truvada

  • Cost: Since 2020, a generic version of Truvada has been available, which has significantly reduced the cost of PrEP. Without insurance, the generic version costs about $30 to $60 per month, making it a much more affordable option for many patients. The branded version of Truvada can still cost between $1,600 to $2,000 per month without insurance, but most people opt for the generic.

  • Insurance: Truvada is widely covered by insurance, and under the Affordable Care Act (ACA), most insured individuals can access PrEP at no out-of-pocket cost.

• Descovy

  • Cost: Descovy remains more expensive since there is currently no generic version available. Without insurance, Descovy typically costs between $1,800 to $2,100 per month. This makes it significantly more expensive than generic Truvada for uninsured patients.

  • Insurance: Like Truvada, Descovy is covered by most insurance plans under the ACA, so insured individuals can generally access it at no out-of-pocket cost.

In the know

• Here are a few lesser-known but important facts about Truvada and Descovy:

  • ‘Polyvalent cations’ and oral PrEP: Both Truvada and Descovy should be taken with caution if you’re using medications or supplements that contain ‘polyvalent cations’. These can reduce the absorption of PrEP, making it less effective. Examples include:

    • Antacids: Medications like Tums or Maalox contain calcium or magnesium.

    • Iron supplements: If you’re taking iron for anemia, it’s best to take PrEP at a different time.

    • Magnesium supplements: Often used for muscle health, magnesium can interfere with PrEP absorption.

To avoid issues, I usually recommend taking PrEP two hours before or after any of these substances.

• Gilead’s Role in Developing PrEP: Gilead Sciences, the pharmaceutical company behind both Truvada and Descovy, held the patent on Truvada until the generic version finally became available in 2020. While Truvada was a major breakthrough for HIV prevention, Gilead developed Descovy as a follow-up medication, marketed as an option with fewer side effects on kidney and bone health. Some critics argue that Gilead developed and patented Descovy to extend its market share and keep PrEP prices high after Truvada went generic. Notably, Gilead has run a strong marketing campaign to promote the “better long term safety” of Descovy. While this is true in some cases, their marketing blitz has proven successful, with many patients switching to the much more expensive Descovy—even in cases when Truvada would’ve been just as safe or in some cases, the safer option.

Which One Is Right for You?

In my clinic, I always take the time to understand my patients’ individual needs and health conditions before recommending a PrEP option.

Here are a few general guidelines for determining which options is right for you:

• Truvada is the best option if you are:

  • At risk of HIV through vaginal sex or injection drug use

  • Looking for a more affordable option (especially with the availability of the generic version)

  • Otherwise healthy, with no significant medical concerns regarding kidney or bone health

• Descovy might be the right choice if you:

  • Do not have receptive vaginal sex or use injection drugs

  • Have underlying medical concerns regarding kidney or bone health

Conclusion

Ultimately, both Truvada and Descovy are highly effective at preventing HIV, and the best option depends on your specific risk factors and health profile. I frequently talk to patients about their lifestyle, medical history, and preferences to help them make the best choice for their health. I encourage you to schedule an appointment with a healthcare provider who can guide you through the decision-making process and help determine which PrEP option may be right for you.

At PridePoint Health, whether you’re a primary care patient or accessing our all-inclusive PrEP & STI services, we’re here to help you navigate your PrEP options and ensure you get the care and support you need to stay healthy and protected. Schedule a Free Meet & Greet or sign up directly on our PrEP page!

Ryan Coe, MD
PridePoint Health

Nothing in this post creates a physician-patient relationship with the reader. 
Speak with your own health care provider prior to making any changes regarding your medications.