{"id":70300,"date":"2026-05-09T07:00:00","date_gmt":"2026-05-09T07:00:00","guid":{"rendered":"https:\/\/medsbase.com\/prep-hiv-prevention\/"},"modified":"2026-05-09T07:00:00","modified_gmt":"2026-05-09T07:00:00","slug":"prep-hiv-prevention","status":"publish","type":"page","link":"https:\/\/medsbase.com\/nl\/prep-hiv-prevention\/","title":{"rendered":"PrEP (Pre-Exposure Profylaxe): Een Compleet Klinisch Handboek voor HIV-preventie"},"content":{"rendered":"<p><!-- prep-hiv-prevention clinical guide --><br \/>\n<script type=\"application\/ld+json\">\n{\n  \"@context\": \"https:\/\/schema.org\",\n  \"@type\": \"MedicalWebPage\",\n  \"name\": \"PrEP (Pre-Exposure Prophylaxis): A Complete Clinical Guide to HIV Prevention\",\n  \"description\": \"Evidence-based clinical reference covering PrEP mechanism, TDF vs TAF, daily and on-demand dosing, baseline testing, monitoring protocols, side effects, resistance, and hepatitis B co-infection.\",\n  \"url\": \"https:\/\/medsbase.com\/prep-hiv-prevention\/\",\n  \"dateModified\": \"2026-05-09\",\n  \"medicalAudience\": {\"@type\": \"Patient\"},\n  \"specialty\": {\"@type\": \"MedicalSpecialty\", \"name\": \"Infectious Disease\"},\n  \"about\": {\"@type\": \"MedicalCondition\", \"name\": \"HIV Prevention\"},\n  \"reviewedBy\": {\"@type\": \"Organization\", \"name\": \"MedsBase Medical Team\"}\n}\n<\/script><\/p>\n<p><script type=\"application\/ld+json\">\n{\n  \"@context\": \"https:\/\/schema.org\",\n  \"@type\": \"FAQPage\",\n  \"mainEntity\": [\n    {\n      \"@type\": \"Question\",\n      \"name\": \"How effective is PrEP at preventing HIV?\",\n      \"acceptedAnswer\": {\"@type\": \"Answer\", \"text\": \"When taken daily with high adherence (\u226595% of doses), TDF\/FTC reduces the risk of sexually acquired HIV by approximately 99% in men who have sex with men (iPrEx trial) and by 75\u201386% in heterosexual adults (Partners PrEP, PROUD). The IPERGAY trial showed event-driven 2-1-1 dosing achieves similar 86% reduction in MSM. Efficacy is directly tied to adherence \u2014 fewer missed doses means better protection.\"}\n    },\n    {\n      \"@type\": \"Question\",\n      \"name\": \"How quickly does PrEP start working?\",\n      \"acceptedAnswer\": {\"@type\": \"Answer\", \"text\": \"Drug levels in rectal tissue reach protective concentrations after approximately 7 days of daily TDF\/FTC (about 4 tablets). For vaginal and cervical tissue, where drug uptake is slower, the protective threshold is not reliably reached until 20 or more days of consecutive dosing. WHO and most national guidelines recommend at least 7 days of daily dosing before relying on PrEP for anal sex, and at least 21 days before relying on it for vaginal sex.\"}\n    },\n    {\n      \"@type\": \"Question\",\n      \"name\": \"What is the difference between TDF\/FTC and TAF\/FTC for PrEP?\",\n      \"acceptedAnswer\": {\"@type\": \"Answer\", \"text\": \"Both provide equivalent HIV prevention efficacy at high adherence. TDF\/FTC (Truvada generics: Tenvir EM, Ricovir EM, Tenof EM, Tavin EM) is the older and cheaper formulation. TAF\/FTC (Descovy; generic: Tenvir AF) delivers the active tenofovir molecule at roughly 90% lower plasma concentrations, which means meaningfully smaller effects on kidney function and bone mineral density. TDF\/FTC is preferred for on-demand (2-1-1) dosing because TAF\/FTC lacks trial data for that regimen. People with pre-existing kidney disease (eGFR 30\u201360 ml\/min) or known low bone density may benefit from TAF\/FTC.\"}\n    },\n    {\n      \"@type\": \"Question\",\n      \"name\": \"What tests are needed before starting PrEP?\",\n      \"acceptedAnswer\": {\"@type\": \"Answer\", \"text\": \"Before starting PrEP: (1) HIV test \u2014 4th-generation Ag\/Ab test to confirm HIV-negative status; do not start PrEP in anyone with confirmed or suspected acute HIV. (2) Hepatitis B surface antigen (HBsAg) \u2014 both TDF and FTC are active against HBV; stopping abruptly in an HBV-positive person can trigger a hepatitis flare. (3) Kidney function \u2014 serum creatinine and estimated GFR; TDF is renally cleared and can cause proximal tubular dysfunction; do not start if eGFR is below 60 ml\/min. (4) Creatinine\/protein in urine. (5) Sexually transmitted infection screening \u2014 gonorrhoea, chlamydia, syphilis.\"}\n    },\n    {\n      \"@type\": \"Question\",\n      \"name\": \"How often should people on PrEP have HIV tests?\",\n      \"acceptedAnswer\": {\"@type\": \"Answer\", \"text\": \"Every 3 months. HIV testing every 3 months is the universal recommendation for anyone on PrEP, regardless of perceived risk. This is non-negotiable: if a person acquires HIV while on PrEP and continues taking TDF\/FTC alone, they risk selecting drug-resistant mutations (especially M184V\/M184I from the emtricitabine component) that could compromise future treatment options. The 3-monthly test also creates a regular touchpoint for STI screening, adherence counselling, and kidney-function monitoring.\"}\n    },\n    {\n      \"@type\": \"Question\",\n      \"name\": \"Can PrEP cause resistance if someone is HIV-positive?\",\n      \"acceptedAnswer\": {\"@type\": \"Answer\", \"text\": \"This is the primary clinical risk of PrEP. Two nucleoside-analog drugs (TDF + FTC) are insufficient to fully suppress HIV in an already-infected person. If someone has undiagnosed HIV when they start PrEP, the partial suppressive pressure can select for the M184V\/M184I mutation (high-level FTC resistance) and, less commonly, K65R (TDF resistance). M184V actually increases susceptibility to TDF, so monotherapy-level resistance is rare, but it can limit future treatment choices. Rigorous baseline and 3-monthly HIV testing eliminates this risk in practice.\"}\n    },\n    {\n      \"@type\": \"Question\",\n      \"name\": \"What happens when someone stops PrEP?\",\n      \"acceptedAnswer\": {\"@type\": \"Answer\", \"text\": \"People with chronic hepatitis B who are stopping TDF\/FTC-based PrEP must do so under medical supervision \u2014 abrupt discontinuation in HBV co-infected individuals can cause a potentially severe hepatic flare as HBV replication rebounds. In HIV-negative, HBV-negative individuals, stopping is straightforward. WHO recommends continuing PrEP for 28 days after the last potential HIV exposure to ensure full post-exposure protection, particularly for vaginal receptive sex where tissue drug levels fall more slowly.\"}\n    },\n    {\n      \"@type\": \"Question\",\n      \"name\": \"Does PrEP protect against other STIs?\",\n      \"acceptedAnswer\": {\"@type\": \"Answer\", \"text\": \"No. PrEP is HIV-specific. It does not protect against gonorrhoea, chlamydia, syphilis, mpox, herpes, HPV, hepatitis A, or hepatitis C. The standard of care for anyone on PrEP is quarterly STI screening (more frequently if symptomatic or high-risk) alongside regular HIV testing. Some PrEP users also incorporate doxycycline post-exposure prophylaxis (Doxy-PEP) \u2014 a single 200 mg dose of doxycycline taken within 72 hours of condomless sex \u2014 which reduces the risk of gonorrhoea, chlamydia, and syphilis by 65\u201387% in MSM and transgender women.\"}\n    }\n  ]\n}\n<\/script><\/p>\n<div style=\"background:#eef7ff;border-left:4px solid #2c7be5;padding:18px 22px;margin:0 0 28px 0;border-radius:6px;\">\n<strong>Clinical summary<\/strong><\/p>\n<ul style=\"margin:10px 0 0 0;\">\n<li><strong>What it is:<\/strong> TDF\/FTC or TAF\/FTC taken by HIV-negative people to prevent HIV acquisition.<\/li>\n<li><strong>Efficacy:<\/strong> ~99% reduction in sexually-acquired HIV at \u226595% adherence (iPrEx, PROUD, Partners PrEP).<\/li>\n<li><strong>Key tests before starting:<\/strong> HIV Ag\/Ab (4th gen), HBsAg, eGFR, creatinine, STI screen.<\/li>\n<li><strong>Monitoring:<\/strong> HIV test + STI screen every 3 months; kidney function every 6 months.<\/li>\n<li><strong>On-demand option:<\/strong> 2-1-1 dosing is evidence-based for MSM using TDF\/FTC (IPERGAY); not established for TAF\/FTC or vaginal sex.<\/li>\n<li><strong>Critical hepatitis B warning:<\/strong> Test HBsAg before starting; stopping TDF\/FTC in HBV-positive people can trigger hepatic flare.<\/li>\n<\/ul>\n<\/div>\n<h1>PrEP (Pre-Exposure Prophylaxis): A Complete Clinical Guide to HIV Prevention<\/h1>\n<div style=\"background:#f6f6f6;border:1px solid #ddd;padding:14px 18px;margin:20px 0;border-radius:6px;font-size:15px;\">\n<strong>Contents<\/strong><\/p>\n<ul style=\"margin:8px 0 0 0;columns:2;\">\n<li><a href=\"#what-is-prep\">What PrEP Is<\/a><\/li>\n<li><a href=\"#who-should-consider\">Who Should Consider PrEP<\/a><\/li>\n<li><a href=\"#mechanism\">How TDF\/FTC Works<\/a><\/li>\n<li><a href=\"#tdf-vs-taf\">TDF vs TAF<\/a><\/li>\n<li><a href=\"#available-options\">Available PrEP Options<\/a><\/li>\n<li><a href=\"#daily-prep\">Daily PrEP: The Evidence<\/a><\/li>\n<li><a href=\"#on-demand\">On-Demand (2-1-1) PrEP<\/a><\/li>\n<li><a href=\"#starting\">Starting PrEP: First Weeks<\/a><\/li>\n<li><a href=\"#baseline-tests\">Baseline Tests<\/a><\/li>\n<li><a href=\"#monitoring\">Monitoring Protocol<\/a><\/li>\n<li><a href=\"#side-effects\">Side Effects &amp; Safety<\/a><\/li>\n<li><a href=\"#hepatitis-b\">Hepatitis B Warning<\/a><\/li>\n<li><a href=\"#interactions\">Drug Interactions<\/a><\/li>\n<li><a href=\"#resistance\">Resistance<\/a><\/li>\n<li><a href=\"#pep-vs-prep\">PEP vs PrEP<\/a><\/li>\n<li><a href=\"#missed-doses\">Missed Doses<\/a><\/li>\n<li><a href=\"#stopping\">Stopping PrEP Safely<\/a><\/li>\n<li><a href=\"#access\">Accessing Generic PrEP<\/a><\/li>\n<li><a href=\"#faq\">Frequently Asked Questions<\/a><\/li>\n<\/ul>\n<\/div>\n<h2 id=\"what-is-prep\">What Is PrEP?<\/h2>\n<p><strong>Pre-exposure prophylaxis (PrEP)<\/strong> is the use of antiretroviral medication by HIV-negative individuals before potential HIV exposure to prevent infection. When taken as prescribed, it is one of the most effective biomedical HIV-prevention strategies ever studied \u2014 more protective than condoms alone, and the only strategy that works silently in the background without requiring any action at the moment of sexual contact.<\/p>\n<p>The standard oral PrEP regimen combines two nucleoside-analog reverse transcriptase inhibitors into a single daily tablet: <strong>tenofovir<\/strong> (in either its older TDF form or newer TAF form) and <strong>emtricitabine<\/strong>. The originator product Truvada (tenofovir disoproxil fumarate 300 mg \/ emtricitabine 200 mg, Gilead Sciences) became the first FDA-approved PrEP medication in 2012. Its patents expired in 2020, and there are now multiple WHO-GMP-certified generic equivalents available globally at a fraction of the originator price.<\/p>\n<p>PrEP is now recommended by the <strong>World Health Organization<\/strong>, the <strong>US Centers for Disease Control and Prevention<\/strong>, the <strong>European AIDS Clinical Society<\/strong>, and virtually every national HIV treatment guideline for any person at substantial ongoing risk of HIV acquisition.<\/p>\n<h2 id=\"who-should-consider\">Who Should Consider PrEP?<\/h2>\n<p>PrEP is appropriate for HIV-negative adults \u2014 and adolescents weighing \u226535 kg \u2014 who face substantial ongoing risk of HIV exposure. &#8220;Substantial risk&#8221; is not defined by identity but by behaviour and context.<\/p>\n<p>The following populations have the strongest evidence base and the most consistent guideline recommendations:<\/p>\n<ul>\n<li><strong>Men who have sex with men (MSM)<\/strong> \u2014 particularly those who have receptive anal sex with partners of unknown or positive HIV status, have multiple concurrent partners, or have a recent STI diagnosis.<\/li>\n<li><strong>Serodiscordant couples<\/strong> \u2014 one partner HIV-positive, one HIV-negative. Even with an undetectable viral load in the positive partner (U=U, Undetectable = Untransmittable), some serodiscordant couples choose PrEP for the negative partner as additional reassurance.<\/li>\n<li><strong>Transgender women<\/strong> who have condomless receptive anal sex with male partners.<\/li>\n<li><strong>Heterosexual adults at ongoing risk<\/strong> \u2014 multiple sexual partners, inconsistent condom use, history of STIs, or sex with a partner at high HIV risk.<\/li>\n<li><strong>People who inject drugs (PWID)<\/strong> \u2014 sharing needles or equipment. PrEP reduces acquisition risk by approximately 49% in this population (Bangkok Tenofovir Study); lower than sexual exposure, reflecting different pharmacokinetics in blood vs genital\/rectal tissue.<\/li>\n<li><strong>Sex workers<\/strong> \u2014 independent of gender or orientation.<\/li>\n<\/ul>\n<p>PrEP is <em>not<\/em> needed for \u2014 and is not recommended for \u2014 people at low or negligible HIV risk. Risk is dynamic: people often cycle on and off PrEP as their circumstances change, and this is explicitly encouraged in WHO and CDC guidance rather than viewed as poor adherence.<\/p>\n<h2 id=\"mechanism\">How TDF\/FTC Works Against HIV<\/h2>\n<p>Both tenofovir and emtricitabine are <strong>pro-drugs<\/strong> \u2014 inactive until phosphorylated by host cell enzymes into their active triphosphate forms inside the cell. The active forms then work by competitive inhibition of HIV reverse transcriptase:<\/p>\n<ol>\n<li>When HIV enters a cell and begins converting its RNA genome into DNA, reverse transcriptase incorporates nucleotide building blocks sequentially.<\/li>\n<li>Intracellular tenofovir diphosphate and emtricitabine triphosphate compete with the natural nucleotides (dATP and dCTP respectively) for incorporation.<\/li>\n<li>Once incorporated, each acts as a <strong>chain terminator<\/strong> \u2014 the viral DNA chain cannot be extended further, halting replication of the viral genome.<\/li>\n<li>Without a complete viral genome, HIV cannot establish latent infection in resting CD4+ T cells.<\/li>\n<\/ol>\n<p>The key to PrEP&#8217;s mechanism is <em>tissue pharmacokinetics<\/em>. HIV establishes infection at mucosal surfaces \u2014 rectal, vaginal, cervical \u2014 before spreading to systemic lymph tissue. TDF\/FTC accumulates in mucosal tissue at concentrations far above the level needed to block reverse transcriptase. With consistent daily dosing:<\/p>\n<ul>\n<li><strong>Rectal tissue<\/strong> reaches protective drug concentrations after approximately <strong>7 days<\/strong> (roughly 4 tablets) of daily dosing \u2014 this is why WHO supports a 7-day lead-in before anal sex.<\/li>\n<li><strong>Vaginal and cervical tissue<\/strong> takes <strong>20 or more days<\/strong> of daily dosing to reach protective concentrations \u2014 a consequence of lower drug uptake in the female genital tract.<\/li>\n<li><strong>Blood<\/strong> reaches steady-state levels much faster but is not the primary site where HIV prevention occurs during sexual exposure.<\/li>\n<\/ul>\n<p>This tissue pharmacokinetics difference is the reason on-demand PrEP (2-1-1) works well for receptive anal sex in MSM but has not been validated for vaginal sex, and why the lead-in period matters.<\/p>\n<h2 id=\"tdf-vs-taf\">TDF\/FTC vs TAF\/FTC: Which to Choose?<\/h2>\n<p>The two tenofovir pro-drugs differ in their off-target systemic toxicity. Both ultimately produce the same intracellular active molecule (tenofovir diphosphate) at similar concentrations in the cells that matter for HIV prevention. The clinical difference is in plasma tenofovir exposure \u2014 TAF produces approximately 90% lower plasma tenofovir levels than TDF, which means substantially less exposure for kidneys and bone.<\/p>\n<table style=\"width:100%;border-collapse:collapse;margin:20px 0;font-size:0.95em;\">\n<thead>\n<tr style=\"background:#2c7cb0;color:#fff;\">\n<th style=\"padding:10px;border:1px solid #ddd;text-align:left;\">Parameter<\/th>\n<th style=\"padding:10px;border:1px solid #ddd;text-align:center;\">TDF\/FTC<\/th>\n<th style=\"padding:10px;border:1px solid #ddd;text-align:center;\">TAF\/FTC<\/th>\n<\/tr>\n<\/thead>\n<tbody>\n<tr>\n<td style=\"padding:9px;border:1px solid #ddd;\">HIV prevention efficacy (\u226595% adherence)<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;text-align:center;\">~99%<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;text-align:center;\">~99%<\/td>\n<\/tr>\n<tr style=\"background:#f9f9f9;\">\n<td style=\"padding:9px;border:1px solid #ddd;\">Plasma tenofovir Cmax<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;text-align:center;\">Higher (systemic)<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;text-align:center;\">~90% lower<\/td>\n<\/tr>\n<tr>\n<td style=\"padding:9px;border:1px solid #ddd;\">Effect on eGFR (kidney filtration rate)<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;text-align:center;\">Modest, reversible decline<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;text-align:center;\">Minimal change<\/td>\n<\/tr>\n<tr style=\"background:#f9f9f9;\">\n<td style=\"padding:9px;border:1px solid #ddd;\">Effect on bone mineral density<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;text-align:center;\">Small decline (~1% hip)<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;text-align:center;\">Stable<\/td>\n<\/tr>\n<tr>\n<td style=\"padding:9px;border:1px solid #ddd;\">Lipid effect (LDL)<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;text-align:center;\">Slight reduction<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;text-align:center;\">Slight increase<\/td>\n<\/tr>\n<tr style=\"background:#f9f9f9;\">\n<td style=\"padding:9px;border:1px solid #ddd;\">On-demand 2-1-1 dosing evidence<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;text-align:center;\">Yes (IPERGAY RCT)<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;text-align:center;\">No established data<\/td>\n<\/tr>\n<tr>\n<td style=\"padding:9px;border:1px solid #ddd;\">Cost (generic per 30-day supply)<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;text-align:center;\">Lower<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;text-align:center;\">Higher<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><strong>Decision guide:<\/strong><\/p>\n<ul>\n<li><strong>Choose TDF\/FTC<\/strong> if you have normal kidney function (eGFR &gt;60 ml\/min) and normal bone density, plan to use on-demand (2-1-1) dosing, or are primarily cost-constrained. TDF\/FTC is the option with the longest real-world evidence base and the broadest global availability in generic form.<\/li>\n<li><strong>Consider TAF\/FTC<\/strong> if you have reduced kidney function (eGFR 30\u201360 ml\/min), known osteoporosis or osteopenia, are over 50 with bone-density risk factors, or are on other medications that increase nephrotoxicity risk alongside TDF.<\/li>\n<li><strong>Avoid both<\/strong> if eGFR &lt;30 ml\/min \u2014 neither formulation is appropriate below this threshold. The injectable long-acting cabotegravir (Apretude, given every 2 months) is a kidney-neutral alternative but is not available as a generic.<\/li>\n<\/ul>\n<h2 id=\"available-options\">Available Generic PrEP Options<\/h2>\n<p>The following WHO-GMP-certified generics provide the same active molecules as originator Truvada (TDF\/FTC) or Descovy (TAF\/FTC):<\/p>\n<p><strong>TDF\/FTC options (generic Truvada equivalents):<\/strong><\/p>\n<ul>\n<li><a href=\"https:\/\/medsbase.com\/tenvir-em\/\"><strong>Tenvir EM<\/strong><\/a> (Cipla) \u2014 the most widely recognised generic TDF 300 mg \/ FTC 200 mg. The brand that aidsmap.com and global PrEP access initiatives have historically referenced as the accessible generic. Cipla is one of the world&#8217;s largest generics manufacturers by volume and supplies WHO-prequalified product to global health programmes.<\/li>\n<li><a href=\"https:\/\/medsbase.com\/ricovir-em\/\"><strong>Ricovir EM<\/strong><\/a> (Hetero Labs) \u2014 clinically equivalent TDF\/FTC generic from another WHO-GMP-certified Indian manufacturer.<\/li>\n<li><a href=\"https:\/\/medsbase.com\/tenof-em\/\"><strong>Tenof EM<\/strong><\/a> (Emcure) \u2014 a further TDF\/FTC equivalent option at a competitive price point.<\/li>\n<li><a href=\"https:\/\/medsbase.com\/tavin-em\/\"><strong>Tavin EM<\/strong><\/a> (Alkem) \u2014 TDF\/FTC generic with equivalent bioavailability.<\/li>\n<li><a href=\"https:\/\/medsbase.com\/taficita\/\"><strong>Taficita<\/strong><\/a> (Cipla) \u2014 another Cipla TDF\/FTC option.<\/li>\n<\/ul>\n<p><strong>TAF\/FTC option (generic Descovy equivalent):<\/strong><\/p>\n<ul>\n<li><a href=\"https:\/\/medsbase.com\/tenvir-af\/\"><strong>Tenvir AF<\/strong><\/a> (Cipla) \u2014 tenofovir alafenamide 25 mg \/ emtricitabine 200 mg. The generic equivalent of Descovy with the improved kidney\/bone safety profile described above.<\/li>\n<\/ul>\n<p><strong>PrEP + Doxy-PEP combination:<\/strong><\/p>\n<ul>\n<li><a href=\"https:\/\/medsbase.com\/prep-starter-pack\/\"><strong>PrEP Starter Pack<\/strong><\/a> \u2014 Tenvir EM paired with doxycycline for Doxy-PEP. Doxycycline 200 mg taken within 72 hours of condomless sex reduces bacterial STI acquisition (gonorrhoea, chlamydia, syphilis) by 65\u201387% in MSM and transgender women (DoxyPEP trial, ANRS IPERGAY STI substudy). Combining oral PrEP with Doxy-PEP addresses both HIV and bacterial STI risk simultaneously.<\/li>\n<\/ul>\n<div style=\"background:#fff8e1;border-left:4px solid #f5a623;padding:16px 20px;margin:24px 0;border-radius:4px;\"><strong>Note on generic equivalence:<\/strong> These are bioequivalent generic medications \u2014 they contain identical active pharmaceutical ingredients at the same dose as the originator. &#8220;Generic&#8221; does not mean lower quality. WHO prequalification and WHO-GMP certification require the same manufacturing standards as originator products. The difference is price, not efficacy or safety.<\/div>\n<h2 id=\"daily-prep\">Daily PrEP: The Evidence Base<\/h2>\n<p>Daily oral TDF\/FTC PrEP has been evaluated in over a dozen large randomised controlled trials and multiple implementation cohorts. The landmark evidence:<\/p>\n<p><strong>iPrEx (2010, N=2,499 MSM and transgender women):<\/strong> TDF\/FTC vs placebo; 44% overall reduction in HIV incidence. In participants with detectable drug levels (indicating high adherence), the reduction was 92\u201399%. Published in <em>NEJM<\/em>; established proof-of-concept for oral PrEP.<\/p>\n<p><strong>Partners PrEP (2012, N=4,758 serodiscordant heterosexual couples):<\/strong> TDF\/FTC reduced HIV acquisition by 75% vs placebo. TDF alone (without FTC) showed similar results. Established efficacy in heterosexual populations in sub-Saharan Africa.<\/p>\n<p><strong>PROUD (2015, UK NHS, N=544 MSM):<\/strong> Real-world immediate vs deferred PrEP. 86% reduction in HIV incidence in the immediate arm, confirming iPrEx findings outside a trial context. Led directly to NHS PrEP provision.<\/p>\n<p><strong>DISCOVER (2020, N=5,387 MSM and transgender women):<\/strong> TAF\/FTC vs TDF\/FTC, head-to-head. Both arms showed 0.16 HIV infections per 100 person-years \u2014 statistically equivalent. TAF\/FTC arm had better kidney and bone outcomes. Led to FDA approval of TAF\/FTC (Descovy) for PrEP.<\/p>\n<p>Across all trials, the headline finding is consistent: at \u226595% adherence (defined as \u22654 tablets\/week in most studies), HIV acquisition in the PrEP arm approaches zero.<\/p>\n<h2 id=\"on-demand\">On-Demand (2-1-1) PrEP<\/h2>\n<p>Event-driven PrEP \u2014 also called &#8220;2-1-1&#8221; after its dosing schedule \u2014 avoids the need for daily tablet-taking while maintaining strong protection for people whose HIV exposure is episodic rather than continuous.<\/p>\n<p><strong>The IPERGAY regimen:<\/strong><\/p>\n<ul>\n<li>Take <strong>2 tablets<\/strong> of TDF\/FTC between 2 and 24 hours before sex.<\/li>\n<li>Take <strong>1 tablet<\/strong> 24 hours after the first dose.<\/li>\n<li>Take <strong>1 tablet<\/strong> 48 hours after the first dose (24 hours after the second).<\/li>\n<li>If sex continues beyond 48 hours after the initial double dose, continue taking 1 tablet daily until 48 hours after the last sexual contact.<\/li>\n<\/ul>\n<p><strong>Evidence:<\/strong> The IPERGAY RCT (N=400 MSM, France\/Canada, 2015) found an 86% reduction in HIV incidence vs placebo. An open-label extension confirmed continued protection with a very low annualised incidence. The ANRS PrEP M\u00e9dicaments analysis and the Au Lait cohort (Paris) confirm real-world effectiveness comparable to daily PrEP in MSM with episodic exposure.<\/p>\n<p><strong>Limitations of 2-1-1:<\/strong><\/p>\n<ul>\n<li>Validated <em>only<\/em> for MSM. There are no completed RCT data in cisgender women, heterosexual men, or people who inject drugs. The slower cervicovaginal drug uptake (20+ days for protective levels) means 2-1-1 does not provide adequate protection for vaginal receptive sex.<\/li>\n<li>Requires planning \u2014 the first 2 tablets must be taken 2\u201324 hours (not less) before sex. Taking them immediately before sex does not provide protection.<\/li>\n<li>Not suitable if taking TDF\/FTC for hepatitis B suppression \u2014 stopping and starting disrupts HBV control.<\/li>\n<li>Not validated for TAF\/FTC. All on-demand data are for TDF\/FTC. WHO does not recommend event-driven dosing with TAF\/FTC products.<\/li>\n<\/ul>\n<h2 id=\"starting\">Starting PrEP: What Happens in the First Weeks<\/h2>\n<p>Understanding the lead-in period helps people stay protected during the weeks before full protection is established:<\/p>\n<table style=\"width:100%;border-collapse:collapse;margin:18px 0;font-size:0.95em;\">\n<thead>\n<tr style=\"background:#2c7cb0;color:#fff;\">\n<th style=\"padding:9px;border:1px solid #ddd;text-align:left;\">Time on Daily TDF\/FTC<\/th>\n<th style=\"padding:9px;border:1px solid #ddd;text-align:left;\">Protection status<\/th>\n<\/tr>\n<\/thead>\n<tbody>\n<tr>\n<td style=\"padding:9px;border:1px solid #ddd;\">Days 1\u20136<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;\">Drug levels building; insufficient for reliable protection. Use condoms.<\/td>\n<\/tr>\n<tr style=\"background:#f9f9f9;\">\n<td style=\"padding:9px;border:1px solid #ddd;\">Day 7 (after ~4 tablets)<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;\">Rectal tissue reaches protective concentrations for receptive anal sex (MSM).<\/td>\n<\/tr>\n<tr>\n<td style=\"padding:9px;border:1px solid #ddd;\">Days 7\u201320<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;\">Protected for anal sex; not yet fully protected for vaginal sex.<\/td>\n<\/tr>\n<tr style=\"background:#f9f9f9;\">\n<td style=\"padding:9px;border:1px solid #ddd;\">Day 21+<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;\">Full protection established for both anal and vaginal sex with daily dosing.<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>People who miss doses during the lead-in period should restart the count. The 7-day rectal \/ 21-day vaginal figures are conservative minimums; tissue pharmacokinetics data suggest some protection accumulates before these thresholds, but the margins are too narrow to rely on.<\/p>\n<h2 id=\"baseline-tests\">Baseline Tests Before Starting PrEP<\/h2>\n<p>These tests are required, not optional. Starting PrEP in an unknowingly HIV-positive person is dangerous (see <a href=\"#resistance\">Resistance<\/a> below).<\/p>\n<ol>\n<li><strong>HIV test (4th-generation Ag\/Ab assay)<\/strong> \u2014 detects both p24 antigen and HIV antibodies, reducing the window period to 18\u201345 days. A 4th-gen negative test together with no high-risk exposure within the preceding 45 days confirms HIV-negative status. If there has been a very recent high-risk exposure (within 45 days), repeat after 45 days of abstinence from further exposure, or test for acute HIV with an RNA assay.<\/li>\n<li><strong>Hepatitis B surface antigen (HBsAg)<\/strong> \u2014 both TDF and FTC have potent anti-HBV activity. Stopping them abruptly in a chronically HBV-infected person can cause severe hepatitis flare. HBV-positive individuals can still take PrEP, but stopping requires a supervised plan with HBV monitoring.<\/li>\n<li><strong>Hepatitis B surface antibody (anti-HBs)<\/strong> \u2014 to confirm vaccination status. If HBsAb is negative and HBsAg negative, offer HBV vaccination before or alongside starting PrEP.<\/li>\n<li><strong>Serum creatinine and estimated GFR (eGFR)<\/strong> \u2014 TDF is renally cleared and can cause proximal tubular dysfunction at high plasma concentrations. Do not start TDF-based PrEP if eGFR &lt;60 ml\/min. TAF-based PrEP can be used down to eGFR 30 ml\/min.<\/li>\n<li><strong>Urine protein:creatinine ratio (uPCR) or dipstick urinalysis<\/strong> \u2014 baseline proteinuria before starting TDF provides a reference point for any future changes.<\/li>\n<li><strong>STI screen<\/strong> \u2014 gonorrhoea and chlamydia (urethral\/rectal\/pharyngeal NAAT as appropriate), syphilis serology, hepatitis C antibody. Not required for PrEP but standard of care and creates a testing baseline for the 3-monthly monitoring schedule.<\/li>\n<li><strong>Hepatitis C antibody<\/strong> \u2014 especially in people who inject drugs.<\/li>\n<\/ol>\n<h2 id=\"monitoring\">Monitoring Protocol While on PrEP<\/h2>\n<table style=\"width:100%;border-collapse:collapse;margin:18px 0;font-size:0.95em;\">\n<thead>\n<tr style=\"background:#2c7cb0;color:#fff;\">\n<th style=\"padding:9px;border:1px solid #ddd;text-align:left;\">Test<\/th>\n<th style=\"padding:9px;border:1px solid #ddd;text-align:center;\">Frequency<\/th>\n<th style=\"padding:9px;border:1px solid #ddd;text-align:left;\">Why<\/th>\n<\/tr>\n<\/thead>\n<tbody>\n<tr>\n<td style=\"padding:9px;border:1px solid #ddd;\">HIV test (4th gen Ag\/Ab)<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;text-align:center;\"><strong>Every 3 months<\/strong><\/td>\n<td style=\"padding:9px;border:1px solid #ddd;\">Non-negotiable. Ongoing PrEP with undetected HIV risks drug resistance.<\/td>\n<\/tr>\n<tr style=\"background:#f9f9f9;\">\n<td style=\"padding:9px;border:1px solid #ddd;\">STI screen (GC\/CT NAAT, syphilis)<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;text-align:center;\">Every 3 months<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;\">STI incidence increases in PrEP cohorts; synergistic HIV risk via genital inflammation.<\/td>\n<\/tr>\n<tr>\n<td style=\"padding:9px;border:1px solid #ddd;\">Serum creatinine + eGFR<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;text-align:center;\">Every 6 months<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;\">TDF proximal tubular toxicity monitoring. Increase to 3-monthly if eGFR is 60\u201390 or declining.<\/td>\n<\/tr>\n<tr style=\"background:#f9f9f9;\">\n<td style=\"padding:9px;border:1px solid #ddd;\">Urine protein (dipstick or uPCR)<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;text-align:center;\">Every 6 months<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;\">Early marker of tubular dysfunction before eGFR falls. Rising protein warrants further evaluation.<\/td>\n<\/tr>\n<tr>\n<td style=\"padding:9px;border:1px solid #ddd;\">Hepatitis C antibody<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;text-align:center;\">Annually (3-monthly if high-risk)<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;\">HCV incidence elevated in some MSM PrEP cohorts; PrEP does not protect against HCV.<\/td>\n<\/tr>\n<tr style=\"background:#f9f9f9;\">\n<td style=\"padding:9px;border:1px solid #ddd;\">Blood pressure + lipids<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;text-align:center;\">Annually<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;\">Routine cardiovascular monitoring; TAF\/FTC may increase LDL modestly.<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><strong>What to do if HIV test comes back positive on PrEP:<\/strong> Stop the two-drug PrEP regimen immediately (it cannot suppress established HIV). Refer urgently to HIV specialist care for genotype resistance testing and initiation of a full 3-drug antiretroviral regimen. The two-drug PrEP exposure may have selected M184V mutation \u2014 genotyping informs which third agents are still fully active.<\/p>\n<h2 id=\"side-effects\">Side Effects and Safety Profile<\/h2>\n<p><strong>Common (usually transient in first 4\u20138 weeks):<\/strong><\/p>\n<ul>\n<li><strong>Nausea, bloating, flatulence<\/strong> \u2014 affects 8\u201316% of new users; typically resolves by week 4\u20136. Take with food to reduce nausea.<\/li>\n<li><strong>Headache<\/strong> \u2014 usually mild and self-limiting.<\/li>\n<li><strong>Fatigue<\/strong> \u2014 reported in trials but rates often similar to placebo arms after adjustment.<\/li>\n<\/ul>\n<p><strong>Kidney effects (TDF-specific):<\/strong><\/p>\n<ul>\n<li>TDF is renally cleared and competes with organic anion transporters in the proximal tubule. This causes a modest, usually reversible decline in eGFR \u2014 on average 3\u20135 ml\/min over the first year in trials. This stabilises and reverses on stopping TDF.<\/li>\n<li>Rare proximal tubulopathy (Fanconi syndrome-like): urinary phosphate wasting, low serum phosphate, glycosuria with normal blood glucose, proteinuria. If this develops, stop TDF and switch to TAF or a non-TDF regimen.<\/li>\n<li>Risk factors for TDF nephrotoxicity: older age, low body weight, pre-existing chronic kidney disease, concurrent nephrotoxic medications (NSAIDs, aminoglycosides, ciclosporin, vancomycin).<\/li>\n<\/ul>\n<p><strong>Bone effects (TDF-specific):<\/strong><\/p>\n<ul>\n<li>Partners PrEP substudy: TDF users had ~1.0% greater decline in hip bone mineral density and ~1.4% greater decline in spine BMD vs placebo over 24 months. This is a small absolute effect and was statistically significant but clinically modest. BMD recovery was observed after stopping TDF.<\/li>\n<li>For individuals with osteoporosis, osteopenia, or significant fracture risk, TAF\/FTC is preferred. Supplemental calcium and vitamin D are reasonable adjuncts for long-term TDF users.<\/li>\n<\/ul>\n<p><strong>Weight:<\/strong> TAF\/FTC is associated with modest weight gain in some cohorts \u2014 a pattern seen across TAF-containing regimens compared to TDF, which has a mild weight-suppressing effect. The mechanism is uncertain and under investigation.<\/p>\n<p><strong>Lipids:<\/strong> TDF\/FTC slightly reduces LDL; TAF\/FTC slightly increases LDL. For people with established cardiovascular disease or high CVD risk, the lipid profiles should factor into the TDF vs TAF decision (noting TDF&#8217;s modest kidney effects outweigh the lipid advantage for most).<\/p>\n<h2 id=\"hepatitis-b\">Hepatitis B \u2014 A Critical Consideration<\/h2>\n<div style=\"background:#fff3f3;border-left:4px solid #d9534f;padding:16px 20px;margin:24px 0;border-radius:4px;\"><strong>Warning \u2014 Hepatitis B co-infection:<\/strong> Both tenofovir and emtricitabine have potent anti-hepatitis-B activity. If a person with chronic HBV infection (HBsAg-positive) starts TDF\/FTC or TAF\/FTC PrEP and then stops \u2014 whether by choice, or because the clinician doesn&#8217;t know about the HBV \u2014 <strong>HBV replication can rebound sharply (hepatic flare)<\/strong>. This can cause acute liver failure. It has caused deaths. Always test for HBsAg before starting. If HBsAg-positive, the person can still take PrEP, but discontinuation must be planned with HBV monitoring and \u2014 if needed \u2014 switching to a different HBV-active agent before stopping TDF\/FTC.<\/div>\n<p>In practice: test HBsAg at baseline. If negative, check vaccination status and offer vaccine. If positive, explain the restart\/stop implications and document the co-infection clearly.<\/p>\n<h2 id=\"interactions\">Drug Interactions<\/h2>\n<table style=\"width:100%;border-collapse:collapse;margin:18px 0;font-size:0.95em;\">\n<thead>\n<tr style=\"background:#2c7cb0;color:#fff;\">\n<th style=\"padding:9px;border:1px solid #ddd;text-align:left;\">Drug \/ Class<\/th>\n<th style=\"padding:9px;border:1px solid #ddd;text-align:left;\">Interaction<\/th>\n<th style=\"padding:9px;border:1px solid #ddd;text-align:left;\">Management<\/th>\n<\/tr>\n<\/thead>\n<tbody>\n<tr>\n<td style=\"padding:9px;border:1px solid #ddd;\">NSAIDs (ibuprofen, naproxen, diclofenac)<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;\">Additive nephrotoxicity with TDF; reduces renal tubular secretion of tenofovir, raising its plasma levels.<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;\">Avoid regular NSAID use with TDF-based PrEP. Paracetamol (acetaminophen) is safe.<\/td>\n<\/tr>\n<tr style=\"background:#f9f9f9;\">\n<td style=\"padding:9px;border:1px solid #ddd;\">Probenecid<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;\">Inhibits renal tubular secretion of TDF, raising tenofovir levels significantly.<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;\">Avoid co-administration or monitor kidney function closely.<\/td>\n<\/tr>\n<tr>\n<td style=\"padding:9px;border:1px solid #ddd;\">Adefovir (HBV drug)<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;\">Additive nephrotoxicity; both compete for organic anion transporters.<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;\">Do not combine; tenofovir replaces adefovir for HBV anyway.<\/td>\n<\/tr>\n<tr style=\"background:#f9f9f9;\">\n<td style=\"padding:9px;border:1px solid #ddd;\">Acyclovir \/ Valacyclovir (herpes antivirals)<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;\">Both renally cleared; at high doses may compete for secretion. Risk is theoretical at standard herpes suppression doses.<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;\">Standard suppressive doses (acyclovir 400 mg twice daily) are acceptable; monitor kidney function as per standard schedule.<\/td>\n<\/tr>\n<tr>\n<td style=\"padding:9px;border:1px solid #ddd;\">Aminoglycosides, vancomycin, ciclosporin, tacrolimus<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;\">Additive nephrotoxicity with TDF.<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;\">Close kidney monitoring if combination necessary; consider TAF\/FTC instead of TDF\/FTC.<\/td>\n<\/tr>\n<tr style=\"background:#f9f9f9;\">\n<td style=\"padding:9px;border:1px solid #ddd;\">Hormonal contraceptives<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;\">No clinically significant pharmacokinetic interaction. TDF\/FTC does not affect hormonal contraception efficacy.<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;\">No action required.<\/td>\n<\/tr>\n<tr>\n<td style=\"padding:9px;border:1px solid #ddd;\">Gender-affirming hormones (estradiol, testosterone)<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;\">No clinically significant interaction established.<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;\">No action required; testosterone does not affect tenofovir PK in published data.<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h2 id=\"resistance\">Resistance \u2014 Understanding the Risk<\/h2>\n<p>Drug resistance from PrEP is a concern that is frequently misunderstood by people researching the topic. Here is what the evidence actually shows:<\/p>\n<p><strong>Why resistance is rare with properly used PrEP:<\/strong> HIV drug resistance requires active viral replication under drug pressure. If someone is genuinely HIV-negative, there is no HIV to develop resistance \u2014 the drugs prevent infection from ever establishing. In correctly selected and monitored PrEP users, resistance cannot arise from the drugs themselves.<\/p>\n<p><strong>The real risk \u2014 undiagnosed HIV at initiation:<\/strong> If someone starts PrEP while unknowingly HIV-positive (e.g., during the window period of a recent infection or due to an acute HIV illness being mistaken for flu), they are effectively taking monotherapy with two drugs insufficient to suppress the virus. In this scenario:<\/p>\n<ul>\n<li><strong>M184V\/M184I<\/strong> \u2014 selected by emtricitabine (and lamivudine) pressure. Confers high-level resistance to FTC and lamivudine, and low-level resistance to TDF (paradoxically, M184V slightly sensitises to TDF by impairing viral fitness). This is the most common mutation selected by inadvertent PrEP use in HIV-positive people.<\/li>\n<li><strong>K65R<\/strong> \u2014 selected by TDF. Confers reduced susceptibility to TDF and TAF. Less commonly selected than M184V when both drugs are present because M184V arises first and reduces viral replication enough to limit further resistance evolution.<\/li>\n<\/ul>\n<p><strong>Real-world frequency:<\/strong> Published reviews of PrEP resistance events indicate M184V is rare (on the order of 1\u20132 per 1,000 person-years of PrEP use in well-monitored programmes), almost exclusively occurring in people starting PrEP during acute\/recent HIV infection missed by baseline testing. The 4th-generation Ag\/Ab assay, used rigorously at baseline, has substantially reduced this risk compared to earlier 3rd-generation antibody tests.<\/p>\n<p><strong>Practical implication:<\/strong> Use a 4th-gen test before starting, test every 3 months while on PrEP, and stop immediately if HIV-positive \u2014 these three steps eliminate the resistance risk in practice.<\/p>\n<h2 id=\"pep-vs-prep\">PEP vs PrEP vs HIV Treatment<\/h2>\n<table style=\"width:100%;border-collapse:collapse;margin:18px 0;font-size:0.95em;\">\n<thead>\n<tr style=\"background:#2c7cb0;color:#fff;\">\n<th style=\"padding:9px;border:1px solid #ddd;text-align:left;\">Strategy<\/th>\n<th style=\"padding:9px;border:1px solid #ddd;text-align:left;\">Who it&#8217;s for<\/th>\n<th style=\"padding:9px;border:1px solid #ddd;text-align:left;\">Regimen<\/th>\n<th style=\"padding:9px;border:1px solid #ddd;text-align:left;\">Duration<\/th>\n<\/tr>\n<\/thead>\n<tbody>\n<tr>\n<td style=\"padding:9px;border:1px solid #ddd;\"><strong>PrEP<\/strong><\/td>\n<td style=\"padding:9px;border:1px solid #ddd;\">HIV-negative adults at ongoing substantial risk<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;\">TDF\/FTC or TAF\/FTC alone (2 drugs)<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;\">Ongoing (daily or event-driven)<\/td>\n<\/tr>\n<tr style=\"background:#f9f9f9;\">\n<td style=\"padding:9px;border:1px solid #ddd;\"><strong>PEP<\/strong><\/td>\n<td style=\"padding:9px;border:1px solid #ddd;\">HIV-negative adults with a specific recent high-risk exposure<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;\">3-drug regimen: TDF\/FTC + integrase inhibitor (usually dolutegravir or raltegravir)<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;\">28 days; must start within 72 hours of exposure<\/td>\n<\/tr>\n<tr>\n<td style=\"padding:9px;border:1px solid #ddd;\"><strong>HIV treatment (ART)<\/strong><\/td>\n<td style=\"padding:9px;border:1px solid #ddd;\">People living with HIV<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;\">3+ drugs (including at least 2 drug classes); backbone often includes TDF\/FTC or TAF\/FTC<\/td>\n<td style=\"padding:9px;border:1px solid #ddd;\">Lifelong<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><strong>PEP is not &#8220;emergency PrEP&#8221;:<\/strong> PEP requires 3 drugs because it is trying to suppress active replication that has already started. It must begin within 72 hours \u2014 the sooner the better, with every hour of delay reducing efficacy. People who find themselves repeatedly needing PEP courses should consider switching to ongoing PrEP.<\/p>\n<p><strong>PrEP is not a substitute for HIV treatment:<\/strong> Two drugs are insufficient to suppress established HIV infection. Never use PrEP as a treatment regimen.<\/p>\n<h2 id=\"missed-doses\">What to Do If You Miss Doses<\/h2>\n<p><strong>Daily regimen:<\/strong><\/p>\n<ul>\n<li>Missed 1 dose: take as soon as remembered; if it&#8217;s almost time for the next dose, skip the missed dose and continue. Do not double up. Protection is marginally reduced by single missed doses but is restored with resumed daily dosing.<\/li>\n<li>Missed 2\u20133 doses in a week: protection is significantly reduced. Use condoms until you have re-established 7 days of consecutive dosing (for anal sex) or 21 days (for vaginal sex).<\/li>\n<li>Missed more than 7 days: consider yourself unprotected. Restart as directed; consider whether a recent high-risk exposure warrants evaluation for PEP.<\/li>\n<\/ul>\n<p><strong>2-1-1 regimen:<\/strong> The pre-sex double dose is non-negotiable \u2014 taking 1 tablet immediately before sex does not provide meaningful protection. If you did not take 2 tablets 2\u201324 hours before sex, use condoms or consider whether a post-exposure PEP course is warranted.<\/p>\n<h2 id=\"stopping\">Stopping PrEP Safely<\/h2>\n<p><strong>For people without hepatitis B (HBsAg negative):<\/strong> WHO recommends continuing PrEP for <strong>28 days after the last potential HIV exposure<\/strong>. This allows residual drug levels in both rectal and vaginal tissue to provide a buffer against any transmission that occurred near the final exposure. Some national guidelines allow a shorter tail (7 days for exclusively receptive anal sex in MSM), but 28 days is a conservative and universal standard.<\/p>\n<p><strong>For people with chronic hepatitis B (HBsAg positive):<\/strong> Do not stop TDF\/FTC or TAF\/FTC abruptly. Discuss with a hepatologist or HIV\/HBV specialist. A planned transition is required \u2014 either to an alternative HBV-active agent before stopping, or supervised dose reduction with liver function and HBV DNA monitoring.<\/p>\n<p><strong>Returning to PrEP:<\/strong> A full restart requires a new HIV test (4th gen) before resuming. If HIV-negative, restart immediately and follow the lead-in period guidance before relying on PrEP for unprotected sex.<\/p>\n<h2 id=\"access\">Accessing Generic PrEP Without a US Prescription<\/h2>\n<p>In the United States, Australia, the UK, and most of Western Europe, PrEP is now available through national healthcare systems or with insurance \u2014 often at low or no cost. In many other countries, however, and for uninsured individuals in the US, the originator brand Truvada can cost over $1,500 per month. This cost barrier is the primary reason people seek generic PrEP internationally.<\/p>\n<p>Cipla&#8217;s <a href=\"https:\/\/medsbase.com\/tenvir-em\/\"><strong>Tenvir EM<\/strong><\/a> contains the identical molecules at the same doses as Truvada, manufactured by one of the world&#8217;s most WHO-prequalified generics manufacturers. It is the product that global PrEP access campaigns, harm-reduction organisations, and HIV-prevention advocates have most consistently named as the accessible alternative to the originator for people outside funded healthcare systems.<\/p>\n<p>For a full comparison of available generic PrEP options, see: <a href=\"https:\/\/medsbase.com\/what-is-hiv-prep-and-how-does-it-work\/\"><strong>Best PrEP Medications (2026): 8 Top HIV Pre-Exposure Prophylaxis Picks Compared<\/strong><\/a>.<\/p>\n<div class=\"medsbase-trust-strip\" style=\"background:#f6f7fb;border:1px solid #e3e5ee;border-radius:8px;padding:14px 18px;margin:24px 0;font-size:14px;line-height:1.55;\"><strong>What you get with MedsBase:<\/strong> Sourced from WHO-GMP certified manufacturers &middot; Discreet plain-envelope packaging &middot; Worldwide Shipping &middot; <a href=\"\/reviews\/\" rel=\"noopener\">1,400+ verified customer reviews<\/a><\/div>\n<p class=\"medsbase-reship-line\" style=\"font-size:14px;color:#444;margin:8px 0 24px;\">\ud83d\udce6 Every order is covered by our <a href=\"https:\/\/medsbase.com\/medsbase-re-shipment-assurance-policy\/\"><strong>Reshipment Assurance Policy<\/strong><\/a> \u2014 if your parcel does not arrive within 20 business days, we reship it.<\/p>\n<h2 id=\"faq\">Frequently Asked Questions<\/h2>\n<h3>How effective is PrEP at preventing HIV?<\/h3>\n<p>When taken daily with high adherence (\u226595% of doses \u2014 roughly \u22654 tablets per week), TDF\/FTC reduces the risk of sexually acquired HIV by approximately 99% in men who have sex with men (iPrEx, PROUD, IPERGAY) and by 75\u201386% in heterosexual adults (Partners PrEP). The IPERGAY trial showed event-driven 2-1-1 dosing achieves a comparable 86% reduction in MSM. Efficacy falls sharply with lower adherence \u2014 the drug must be in tissue to work.<\/p>\n<h3>How quickly does PrEP start working?<\/h3>\n<p>Drug levels in rectal tissue reach protective concentrations after approximately 7 days of daily TDF\/FTC (roughly 4 consecutive tablets). For vaginal and cervical tissue, where drug uptake is slower, the protective threshold is not reliably reached until 20 or more days of consecutive daily dosing. WHO recommends at least 7 days of lead-in for anal sex and at least 21 days for vaginal sex before relying on PrEP without condoms.<\/p>\n<h3>What is the difference between TDF\/FTC and TAF\/FTC for PrEP?<\/h3>\n<p>Both provide equivalent HIV prevention efficacy at high adherence. TDF\/FTC (originator Truvada; generics: Tenvir EM, Ricovir EM, Tenof EM, Tavin EM) is the older and less expensive formulation. TAF\/FTC (originator Descovy; generic: Tenvir AF) produces approximately 90% lower plasma tenofovir levels, which translates into meaningfully smaller effects on kidney function and bone mineral density. TDF\/FTC is preferred for on-demand (2-1-1) dosing because TAF\/FTC lacks validated trial data for that regimen. People with pre-existing kidney disease (eGFR 30\u201360 ml\/min) or known low bone density are better candidates for TAF\/FTC.<\/p>\n<h3>What tests are needed before starting PrEP?<\/h3>\n<p>Required baseline tests: (1) 4th-generation HIV Ag\/Ab test to confirm HIV-negative status. (2) Hepatitis B surface antigen (HBsAg) \u2014 both TDF and FTC suppress HBV, and stopping abruptly in an HBV-positive person can trigger a dangerous hepatic flare. (3) Serum creatinine and eGFR \u2014 do not start TDF-based PrEP if eGFR &lt;60 ml\/min. (4) Urine protein (dipstick or uPCR). (5) STI screen \u2014 gonorrhoea, chlamydia, syphilis serology.<\/p>\n<h3>How often should people on PrEP have HIV tests?<\/h3>\n<p>Every 3 months \u2014 this is non-negotiable. If a person acquires HIV while on PrEP and continues taking TDF\/FTC alone (two drugs, insufficient for HIV treatment), they risk selecting the M184V mutation \u2014 which confers high-level FTC resistance and may limit future treatment choices. The 3-monthly test also serves as a touchpoint for STI screening, adherence counselling, and kidney monitoring.<\/p>\n<h3>Can PrEP cause resistance if someone is already HIV-positive?<\/h3>\n<p>PrEP cannot cause resistance in a genuinely HIV-negative person \u2014 there is no HIV to develop resistance against. The risk is specifically if someone starts PrEP while unknowingly HIV-positive (undiagnosed recent infection within the window period). In that scenario, TDF\/FTC alone provides insufficient suppression, and the emtricitabine component can select the M184V mutation. Rigorous 4th-generation testing before starting, and 3-monthly testing while on PrEP, eliminates this risk in practice.<\/p>\n<h3>What happens when someone stops PrEP?<\/h3>\n<p>In HIV-negative, HBV-negative individuals: continue for 28 days after the last potential HIV exposure to allow tissue drug levels to fall gradually. Stopping abruptly after the last exposure leaves a brief window of diminishing protection \u2014 the 28-day tail closes this gap. People with chronic hepatitis B must not stop TDF\/FTC abruptly \u2014 the anti-HBV activity of the drugs suppresses HBV replication, and stopping can cause a dangerous hepatic flare. A managed discontinuation under medical supervision is required.<\/p>\n<h3>Does PrEP protect against other STIs?<\/h3>\n<p>No. PrEP is HIV-specific. It does not protect against gonorrhoea, chlamydia, syphilis, mpox, herpes, HPV, hepatitis C, or hepatitis A. The standard of care for anyone on PrEP is quarterly STI screening alongside the required 3-monthly HIV test. Some PrEP users also incorporate doxycycline post-exposure prophylaxis (Doxy-PEP) \u2014 200 mg doxycycline within 72 hours of condomless sex \u2014 which reduces bacterial STI risk by 65\u201387% in MSM and transgender women (DoxyPEP trial). The <a href=\"https:\/\/medsbase.com\/prep-starter-pack\/\">PrEP Starter Pack<\/a> combines Tenvir EM with doxycycline for this combined approach.<\/p>\n<div style=\"background:#fff3f3;border-left:4px solid #d9534f;padding:14px 18px;margin:32px 0;border-radius:4px;font-size:14px;\"><strong>Medical Disclaimer:<\/strong> This page provides clinical information for educational purposes. It does not replace a consultation with a qualified healthcare provider. HIV testing, hepatitis B screening, and kidney function assessment are required before starting PrEP. If you have symptoms that may indicate acute HIV infection (fever, rash, swollen lymph nodes within 2\u20134 weeks of a high-risk exposure), do not rely on a standard antibody test \u2014 seek medical assessment immediately for RNA testing.<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Clinical summary What it is: TDF\/FTC or TAF\/FTC taken by HIV-negative people to prevent HIV acquisition. Efficacy: ~99% reduction in sexually-acquired HIV at \u226595% adherence (iPrEx, PROUD, Partners PrEP). Key tests before starting: HIV Ag\/Ab (4th gen), HBsAg, eGFR, creatinine, STI screen. Monitoring: HIV test + STI screen every 3 months; kidney function every 6 [&#8230;]\n","protected":false},"author":0,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-70300","page","type-page","status-publish","hentry"],"acf":[],"rankMath":{"parentDomain":"medsbase.com","noFollowDomains":[],"noFollowExcludeDomains":[],"noFollowExternalLinks":true,"featuredImageNotice":"The featured image should be at least 200 by 200 pixels to be picked up by Facebook and other social media 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