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Emtricitabine and tenofovir alafenamide vs emtricitabine and tenofovir disoproxil fumarate for HIV pre-exposure prophylaxis (DISCOVER) primary results from a randomised, double-blind, multicentre, active-controlled, phase 3, non-inferiority trial
Open accessAbstract
Background Tenofovir alafenamide shows high antiviral efficacy and improved renal and bone safety compared with tenofovir disoproxil fumarate when used for HIV treatment. Here, we report primary results from a blinded phase 3 study evaluating the efficacy and safety of pre-exposure prophylaxis (PrEP) with emtricitabine and tenofovir alafenamide versus emtricitabine and tenofovir disoproxil fumarate for HIV prevention.Methods This study is an ongoing, randomised, double-blind, multicentre, active-controlled, phase 3, non-inferiority trial done at 94 community, public health, and hospital-associated clinics located in regions of Europe and North America, where there is a high incidence of HIV or prevalence of people living with HIV, or both. We enrolled adult cisgender men who have sex with men and transgender women who have sex with men, both with a high risk of acquiring HIV on the basis of their self-reported sexual behaviour in the past 12 weeks or their recent history (within 24 weeks of enrolment) of bacterial sexually transmitted infections. Participants with current or previous use of PrEP with emtricitabine and tenofovir disoproxil fumarate were not excluded. We used a computer-generated random allocation sequence to randomly assign (1:1) participants to receive either emtricitabine (200 mg) and tenofovir alafenamide (25 mg) tablets daily, with matched placebo tablets (emtricitabine and tenofovir alafenamide group), or emtricitabine (200 mg) and tenofovir disoproxil fumarate (300 mg) tablets daily, with matched placebo tablets (emtricitabine and tenofovir disoproxil fumarate group). As such, all participants were given two tablets. The trial sponsor, investigators, participants, and the study staff who provided the study drugs, assessed the outcomes, and collected the data were masked to group assignment. The primary efficacy outcome was incident HIV infection, which was assessed when all participants had completed 48 weeks of follow-up and half of all participants had completed 96 weeks of follow-up. This full analysis set included all randomly assigned participants who had received at least one dose of the assigned study drug and had at least one post-baseline HIV test. Non-inferiority of emtricitabine and tenofovir alafenamide to emtricitabine and tenofovir disoproxil fumarate was established if the upper bound of the 95·003% CI of the HIV incidence rate ratio (IRR) was less than the prespecified non-inferiority margin of 1·62. We prespecified six secondary bone mineral density and renal biomarker safety endpoints to evaluate using the safety analysis set. This analysis set included all randomly assigned participants who had received at least one dose of the assigned study drug. This trial is registered with ClinicalTrials.gov, NCT02842086, and is no longer recruiting.Findings Between Sept 13, 2016, and June 30, 2017, 5387 (92%) of 5857 participants were randomly assigned and received emtricitabine and tenofovir alafenamide (n=2694) or emtricitabine and tenofovir disoproxil fumarate (n=2693). At the time of the primary efficacy analysis (ie, when all participants had completed 48 weeks and 50% had completed 96 weeks) emtricitabine and tenofovir alafenamide was non-inferior to emtricitabine and tenofovir disoproxil fumarate for HIV prevention, as the upper limit of the 95% CI of the IRR, was less than the prespecified non-inferiority margin of 1·62 (IRR 0·47 [95% CI 0·19-1·15]). After 8756 person-years of follow-up, 22 participants were diagnosed with HIV, seven participants in the emtricitabine and tenofovir alafenamide group (0·16 infections per 100 person-years [95% CI 0·06-0·33]), and 15 participants in the emtricitabine and tenofovir disoproxil fumarate group (0·34 infections per 100 person-years [0·19-0·56]). Both regimens were well tolerated, with a low number of participants reporting adverse events that led to discontinuation of the study drug (36 [1%] of 2694 participants in the emtricitabine and tenofovir alafenamide group vs 49 [2%] of 2693 participants in the emtricitabine and tenofovir disoproxil fumarate group). Emtricitabine and tenofovir alafenamide was superior to emtricitabine and tenofovir disoproxil fumarate in all six prespecified bone mineral density and renal biomarker safety endpoints.Interpretation Daily emtricitabine and tenofovir alafenamide shows non-inferior efficacy to daily emtricitabine and tenofovir disoproxil fumarate for HIV prevention, and the number of adverse events for both regimens was low. Emtricitabine and tenofovir alafenamide had more favourable effects on bone mineral density and biomarkers of renal safety than emtricitabine and tenofovir disoproxil fumarate.Funding Gilead Sciences.
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“The successful development and widespread adoption of these prophylactics has been considered a public health triumph, drastically reducing the spread of HIV, and dramatically improving quality of life (Mayer et al., 2020).”
From The Need for Biological Countermeasures to Mitigate the Risk of Space Radiation-Induced Carcinogenesis, Cardiovascular Disease, and Central Nervous System Deficiencies (2022) · cites this paper as Mayer et al., 2020
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“For example, individuals at high-risk of contracting the human immunodeficiency virus (HIV) routinely take the prophylactic tenofovir with emtricitabine formulations (daily oral administration) that prevent (and treat) HIV infection.”
From The Need for Biological Countermeasures to Mitigate the Risk of Space Radiation-Induced Carcinogenesis, Cardiovascular Disease, and Central Nervous System Deficiencies (2022) · cites this paper as Mayer et al., 2020
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“This paradigm has since evolved, as prophylactic compound approaches have been shown to improve health outcomes in healthy populations which are at risk.”
From The Need for Biological Countermeasures to Mitigate the Risk of Space Radiation-Induced Carcinogenesis, Cardiovascular Disease, and Central Nervous System Deficiencies (2022) · cites this paper as Mayer et al., 2020
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Contemporary Treatment Approaches for Human Immunodeficiency Virus Infection
Shroba, J., & Januszka, J. E. (2024) · Nursing Clinics of North America · doi:10.1016/j.cnur.2024.01.004
Pre-exposure Prophylaxis for Transgender People: A Systematic Review
Pérez-Alba, E., Condori, R. C. I., Cantú-Hernández, J. A., Álvarez‐Villalobos, N. A., Salinas-Garza, L. A., & Camacho-Ortíz, A. (2024) · Clinical Infectious Diseases · doi:10.1093/cid/ciae226
Profilassi Pre-Esposizione (PrEP): uno dei caposaldi nella prevenzione dell’infezione da HIV.
Pagnucco, L. (2024) · JHA - Journal of HIV and Ageing · doi:10.19198/jha31575
Reassuring long-term safety, resistance, and efficacy data for two daily formulations of PrEP
Donnell, D. J. (2024) · The Lancet HIV · doi:10.1016/s2352-3018(24)00158-9
Cantos, V. D., Neradilek, M. B., Huang, Y., Roxby, A. C., Gillespie, K., deCamp, A. C., Karuna, S., Edupuganti, S., Gallardo-Cartagena, J. A., Sánchez, J., et al. (2024) · Open Forum Infectious Diseases · doi:10.1093/ofid/ofae387
“Oral [1, 2] and injectable [3, 4] preexposure prophylaxis (PrEP) is highly effective in preventing human immunodeficiency virus (HIV) acquisition; however, existing PrEP modalities may not fulfill the needs of all people due to comorbidities, limited local access, cost, or individual preference [4].”
Backgroundde Vos, L., Mussa, A., Rousseau, E., Strauss, M., George, G., Vundhla, P., Gebengu, A., Tsuaneng, M., Tamuthiba, L., Tumagole, A., et al. (2024) · Research Square · doi:10.21203/rs.3.rs-4802607/v1
Infecciones de transmision sexual en la era de la PrEP
de Loredo, N., & Blanco, J. L. (2024) · Actualizaciones en Sida e Infectología · doi:10.52226/revista.v32i115.334
Sewell, J., Witzel, T. C., Dunn, D. T., Lampe, F. C., Burns, F. M., Weatherburn, P., McCormack, S., McCabe, L., Miners, A. H., Cambiano, V., et al. (2024) · Programme Grants for Applied Research · doi:10.3310/ayhe4598
Merchant, E. A., Solleveld, P., Gibas, K. M., & Krakower, D. (2024) · PLoS ONE · doi:10.1371/journal.pone.0311591
“TAF/FTC was demonstrated to be non-inferior to TDF/FTC for the prevention of new HIV infections among men who have sex with men and transgender women in the DISCOVER trial [5].”
Weimer, A. K. (2024) · Springer eBooks · doi:10.1007/978-3-031-69997-9_3
McGarrity, M. W., MacPherson, P. A., Li, A., Naccarato, M., Anderson, P. L., & Tan, D. H. S. (2025) · HIV Medicine · doi:10.1111/hiv.13759
“Another combination used as PrEP is tenofovir alafe-namide (TAF) with FTC, which has been demonstrated to have non-inferior HIV prevention efficacy compared with TDF/FTC among men who have sex with men [7].”
Self-citationTheorizing Sexual Health Vulnerability, Redefining Risk, and Identifying Research Question(s)
Dangerfield, D. T. (2025) · Springer eBooks · doi:10.1007/978-3-031-85130-8_2
Bolluyt, D. C., van den Elshout, M. A. M., Wijstma, E. S., Boyd, A. C., Hoornenborg, E., de Vries, H. J. C., Prins, M., Vogt, L., van der Loeff, M. F. S., van Benthem, T., et al. (2025) · Kidney International Reports · doi:10.1016/j.ekir.2025.03.033
“People with decreased kidney function who are vulnerable to HIV require a tailored approach, using more frequent kidney function monitoring during PrEP follow-up or other PrEP modalities with a better renal safety pro fi le, such as tenofoviralafenamide 38 or cabotegravir.”
Dunn, D. T., McCormack, S., Kusemererwa, S., Munseri, P., Singh, N., Mutonyi, G., Bern, H., Goldwirt, L., Kingsley, C. I., Kroidl, A., et al. (2025) · SSRN Electronic Journal · doi:10.2139/ssrn.5236675
Jorgensen, P. E. W., Ruiz‐Algueró, M., Iniesta, C., Pulido, F., & Llenas‐García, J. (2025) · Enfermedades infecciosas y microbiologia clinica (English ed ) · doi:10.1016/j.eimce.2024.12.014
Silva, C. J., Arrington‐Sanders, R., Goldstein, Z. G., Imbert, E., Hickey, M. D., Asupoto, O., Wurcel, A. G., Davids, A., Carvalho, A., García, D., et al. (2025) · Oxford University Press eBooks · doi:10.1093/med/9780197812631.003.0010
Baumgartner, K., Bositis, C. M., Hanft, W., & Chu, C. (2025) · Oxford University Press eBooks · doi:10.1093/med/9780197812631.003.0014
Antiretroviral Therapy Selection/Decision-Making
Ajmal, S., Temesgen, Z., Mathur, P., & Koren, D. E. (2025) · Oxford University Press eBooks · doi:10.1093/med/9780197812631.003.0015
May, E. R., Mu, L., Turvey, S. L., Chew, D. S., Tonelli, M. A., Klarenbach, S. W., Pannu, N., Christie, E. A., Thompson, S., Bello, A. K., et al. (2025) · Canadian Journal of Infectious Diseases and Medical Microbiology · doi:10.1155/cjid/9340622
“…and TAF/FTC are equivalent for HIV PrEP is consistent with previous literature as TAF/FTC has been shown to be noninferior to TDF/FTC with better kidney and bone biomarker safety [5] but increased weight gain and dyslipidemia [34], and, more recently, incident hypertension and statin use [35].”
Jackson, K. J., Tomlinson, S., & Klotzbaugh, R. J. (2025) · Journal of the American Association of Nurse Practitioners · doi:10.1097/jxx.0000000000001177
Kim, H. Y., Liebenberg, A., Zhang, L., & von Kleist, M. (2025) · medRxiv · doi:10.1101/2025.08.26.25334527
“For example, the fraction of MSM not taking oral TDF/FTC-based PrEP was only 4–21% in major clinical studies like IPERGAY, HPTN 083, Purpose 2 and DISCOVER [11,14,50,51], whereas it was 44, 64, 71 and ≈ 90% of cis-gender women in HPTN 084, Fem-PrEP, VOICE and Purpose 1 [10, 12, 52, 53].”
Analysis of potential barriers for non-PrEP users among MSM in GermanyPreprint
Waldorf, H., Marcus, U., Iannuzzi, S., Albrecht, S., Hoebel, J., Gunsenheimer‐Bartmeyer, B., Bremer, V., von Kleist, M., & Koppe, U. (2025) · medRxiv · doi:10.1101/2025.08.29.25334713
Re-evaluating STI prophylaxis following sexual assault: The role of DoxyPEP
Mirza, H., Fowler, C., & Soni, S. (2025) · International Journal of STD & AIDS · doi:10.1177/09564624251374151
“18 Data for the effectiveness of doxyPEP in this population is limited to one RCT which found no statistically signi fi cant reduction in bacterial STIs.”
HIV Pre-Exposure Prophylaxis for the General Ob/Gyn
Rager, T. L., & Davies, J. (2025) · Topics in Obstetrics & Gynecology · doi:10.1097/01.pgo.0001168036.42041.b5
Sample size estimation for the averted events ratio
Dunn, D. T., Stirrup, O., & Glidden, D. V. (2025) · Clinical Trials · doi:10.1177/17407745251377435
Mesner, O., Jain, R., Ramakrishnan, A., Matthews, D. D., & Goldbach, J. T. (2025) · Open Forum Infectious Diseases · doi:10.1093/ofid/ofaf605
The effects of HIV on bone and muscle health through the lifespan in populations living in Africa
Jeena, L., Mukwasi-Kahari, C., Ward, K. A., & Gregson, C. L. (2025) · AIDS · doi:10.1097/qad.0000000000004307
Tenofovir alafenamide fumarate use for HIV pre-exposure prophylaxis and weight gain
Shi, F., Xia, H., Weissman, S., Li, X., & Yang, X. (2025) · Scientific Reports · doi:10.1038/s41598-025-23810-5
Mendonça, P. K., Santos, D. M. D., do Nascimento, A. I., da Cunha, J. C. P., Koch, G. S. R., Maciel, C. G., Santos-Pinto, C. D. B., & de Oliveira, E. F. (2025) · BMC Public Health · doi:10.1186/s12889-025-25812-4
Pre-Exposure Prophylaxis (PrEP)-Associated HIV Monitoring and Self-Testing
Zhu, Y., & Sell, J. K. (2025) · Clinical Chemistry · doi:10.1093/clinchem/hvaf155 · Cited by 1
Guimarães, N. S., Magno, L., Monteiro, G. M. B., Ramos, I. C. N., de Castro, C. T., ROSSI, T. A., Pereira, M., & Dourado, I. (2024) · Figshare · doi:10.6084/m9.figshare.26639782
Brázia, J., Wang, B., Meireles, P., Valdano, E., & Teixeira, A. S. (2025) · Research Square · doi:10.21203/rs.3.rs-8226143/v1 · Cited by 1
Reversible Effects of Integrase Inhibitors on Newly Differentiated Adipocytes
Pickering, R. T., Asundi, A., Olson, A. J., Soden, K., & Lin, N. (2026) · Viruses · doi:10.3390/v18010149
“This is especially relevant given the ongoing examination of the relative effects of INSTIs versus their coformulation with tenofovir alafenamide, which has well-documented effects on weight gain [37,38].”
Barbaro, F., Sasset, L., Zenere, A., Scaglione, V., Cavinato, S., Gardin, S., Leoni, D., Calandrino, L., Vania, E., Colombo, F., et al. (2026) · doi:10.2196/preprints.92280
Reimagining HIV Prevention for Women
Chandler, R. D., Warner, S. C., Johnson, R., & Wells, J. (2025) · Clinical Journal for Nurse Practitioners in Women s Health · doi:10.1891/cjnpwh-2025-0030
White, A., Villa, G. C. F., Crowley, V., Murphy, D. M., Quinn, L. L., O’Sullivan, C., Courtney, G., Griffin, B., & Devitt, E. J. (2026) · Sexually Transmitted Infections · doi:10.1136/sextrans-2025-056766
Metadata
- Authors
- Mayer, K. H., Molina, J.-M., Thompson, M. A., Anderson, P. L., Mounzer, K. C., De Wet, J. J., DeJesus, E., Jessen, H., Grant, R. M., Ruane, P. J., Wong, P., Ebrahimi, R., Zhong, L., Mathias, A., Callebaut, C., Collins, S. E., Das, M., McCallister, S., Brainard, D. M., Brinson, C., Clarke, A., Coll, P., Post, F. A., & Hare, C. B.
- Affiliations
- Harvard University (US)
- Inserm (FR)
- AIDS Research Consortium of Atlanta (US)
- University of Colorado Anschutz (US)
- Philadelphia Fight (US)
- Orlando Immunology Center (US)
- University of California, San Francisco (US)
- Ruane Medical (US)
- Gilead Sciences (United States) (US)
- National Health Service (GB)
- IrsiCaixa (ES)
- King's College Hospital NHS Foundation Trust (GB)
- Kaiser Permanente San Francisco Medical Center (US)
- Corresponding author
- Das, Moupali
- ORCID
- Venue
- The Lancet
- Publisher
- Elsevier BV
- Published
- 2020-07
- Volume
- 396
- Issue
- 10246
- Pages
- 239-254
- ISSN
- 0099-5355 (ISSN-L)
- 0140-6736
- PMC
- PMC9665936
- OpenAlex
- W3045256412
- Cited by
- 428
- References
- 61
- Citations by year
- 2026: 38 · 2025: 68 · 2024: 72 · 2023: 76 · 2022: 88 · 2021: 72 · 2020: 13
- FWCI
- 8.17
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- The Lancet (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Gilead Sciences
- Topics
- Health Sciences › Medicine › Infectious Diseases › HIV/AIDS Research and Interventions
- Health Sciences › Medicine › Infectious Diseases › HIV/AIDS drug development and treatment
- Life Sciences › Immunology and Microbiology › Virology › HIV Research and Treatment
- Keywords
- HIV pre-exposure prophylaxis, tenofovir alafenamide, tenofovir disoproxil fumarate, emtricitabine, HIV prevention, non-inferiority, men who have sex with men, transgender women, renal safety, bone safety, antiviral efficacy, sexually transmitted infections
- MeSH terms
- Emtricitabine, Tenofovir, Emtricitabine, Tenofovir Disoproxil Fumarate Drug Combination, Sexual and Gender Minorities, Adenine, Adult, Double-Blind Method, Europe, Female, Humans, Male, North America, Placebos, Safety, HIV-1, HIV Infections, Prevalence, Treatment Outcome, Homosexuality, Male, Anti-HIV Agents, Pre-Exposure Prophylaxis
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