Academy Exchange

I am seeing a transgender patient who is interested in PrEP. He has decreased renal function, with calculated CrCl is 51.512, sees nephrology for Stage 3 CKD.  As a biological female, med options are Truvada (emtricitabine-TDF) and Apretude (cabotegravir). HIV 1/2AB p24 AG Non-reactive 4/18/25. 

Truvada has warnings for persons with CKD: The tenofovir disoproxil fumarate component of this product is associated with proximal tubular injury, Fanconi syndrome, and progression of chronic kidney disease (CKD). Avoid use in patients with preexisting CKD (eGFR <60 mL/minute/1.73 m²).

He is interested in Apretude injections, which seem to be a better fit.  However, his insurance will not cover testing HIV-1 Quant Viral Load. This is listed in the drug monograph as the preferred test due to coverage for acute HIV infection. The cash price for this test is $450. 

What do you recommend in this case? My plan is to request that he complete this test once as recommended, then switch to HIV 1/2AB p24 AG testing for followup, if our team agrees. I would be grateful for any advice on the best approach in this situation. 

Any recommendations?  Thank you very much for your input. 

Barbara Hart APRN

Hi Barbara,

Try ordering a qualitative HIV RNA instead.  This assay is more likely to be covered.  Make sure you use the appropriate ICD 10 code as well.     If insurance still will not cover, you could just get away with a 4th gen, especially if he has not had a recent high risk encounter.    The requirement for an HIV RNA test  may be going away in the near future  anyway.    Good luck!

I am seeing a transgender patient who is interested in PrEP. He has decreased renal function, with calculated CrCl is 51.512, sees nephrology for Stage 3 CKD.  As a biological female, med options are Truvada (emtricitabine-TDF) and Apretude (cabotegravir). HIV 1/2AB p24 AG Non-reactive 4/18/25. 

Truvada has warnings for persons with CKD: The tenofovir disoproxil fumarate component of this product is associated with proximal tubular injury, Fanconi syndrome, and progression of chronic kidney disease (CKD). Avoid use in patients with preexisting CKD (eGFR <60 mL/minute/1.73 m²).

He is interested in Apretude injections, which seem to be a better fit.  However, his insurance will not cover testing HIV-1 Quant Viral Load. This is listed in the drug monograph as the preferred test due to coverage for acute HIV infection. The cash price for this test is $450. 

What do you recommend in this case? My plan is to request that he complete this test once as recommended, then switch to HIV 1/2AB p24 AG testing for followup, if our team agrees. I would be grateful for any advice on the best approach in this situation. 

Any recommendations?  Thank you very much for your input. 

Barbara Hart APRN