Bone Health Considerations for PrEP Users

Bone Effects of TDF-Based PrEP

• TDF-based PrEP has been associated with a 1% to 1.5% loss of bone mineral density at 48 weeks at the hip and spine, with return to baseline upon discontinuation of PrEP 1, 2, 3

Risk Assessment and Recommendations

• Due to the TDF component, TDF-based PrEP is not recommended for those with pre-existing osteopenia or osteoporosis (evidence rating AIII) 1, 2, 3
• Individuals at high risk of osteopenia or osteoporosis should carefully weigh the risks and benefits of TDF-based PrEP 2, 3
• For men who have sex with men (MSM) with or at risk for kidney dysfunction, osteopenia, or osteoporosis, daily tenofovir alafenamide/emtricitabine (TAF/FTC) is recommended instead of TDF/FTC (evidence rating: BIa) 4, 5

Monitoring and Management

• While specific bone density monitoring guidelines for PrEP users are not established in current guidelines, clinicians should consider baseline and follow-up bone health assessments for individuals with risk factors for osteoporosis 2, 6

Clinical Decision Making

• For patients with pre-existing bone disease who require PrEP, consider using TAF/FTC instead of TDF/FTC for MSM at risk for osteoporosis 4, 5