There’s a lot of information about PrEP available, but most of it is directed towards bottoms. This can leave tops considering PrEP with more questions than answers. 

Do tops even need to take PrEP? What is my risk of HIV infection if I don’t use PrEP? Do I need to take PrEP if I’m consistently using condoms?

Many tops do use PrEP to reduce their risk of HIV infection, and for additional peace of mind, but it’s a personal choice. You deserve to have the information you need and your questions answered before deciding if PrEP is the right option for you. 

To help you out, we’ll walk through some of the misconceptions surrounding PrEP for tops, discuss why tops choose to take it, and go through some considerations to discuss with a clinician before starting PrEP.

Short answer: Tops can benefit from PrEP, too

Tops can benefit from taking PrEP to reduce their HIV risk. But there’s a lot of mixed messaging out there about how tops contract HIV, which can add some confusion.

Anal sex carries a higher HIV transmission risk than many other types of sex, but risk varies by role. Receptive anal sex generally carries higher risk, while insertive anal sex, or topping, carries lower but still possible risk.

Because of this, many tops take PrEP so they can enjoy their sexual activities with peace of mind and extra protection.

Is PrEP only for bottoms? (Myth vs reality)

It’s a common misconception that PrEP is only for bottoms. PrEP is for everyone: tops, bottoms, and people who enjoy both. 

The reason this misconception exists is because you are more likely to get HIV while bottoming. While receptive anal intercourse (bottoming) carries a high risk of HIV transmission, insertive anal sex, or topping, still carries a risk of HIV transmission as well. 

There are a few different factors that can increase your risk of HIV infection while topping.

  • Your partner’s viral load levels: There can be high levels of the virus in a bottom’s rectal secretions and blood, putting tops at risk of infection. 
  • A recent infection: If someone was recently infected with HIV, their viral load is typically very high, increasing the risk of transmission. If your partner was recently infected, they might not know they have an HIV infection yet and unknowingly put you at risk. 
  • You have an untreated STI: If you have an STI, you could have sores, lesions, or ulcers that make it easier for HIV to enter your body. There is also often a higher concentration of immune cells at STI infection sites, which are more prone to HIV infection.
  • Your partner has another untreated STI: Other STIs can increase HIV shedding in people who have an HIV infection, but are not taking treatment.

If you are curious about PrEP, you won’t be turned away because of your preferences. Clinicians determine eligibility based on your risk factors and what you’re comfortable with, not the fact that you’re a top.

Many tops use PrEP, and if it feels like the right choice for you, your clinician can support you to determine the best next steps. 

When PrEP may make sense for tops

Because there’s less information about PrEP for tops out there, you might need some guidance about when you might want to consider using it. 

Here are some scenarios where PrEP might be the right choice for tops: 

  • When you have multiple partners and don’t know the HIV status of their other partners
  • When you’re casually dating and may have a sexual encounter before knowing someone’s status
  • If you aren’t consistently using condoms during sex
  • If your partner doesn’t know their HIV status or hasn’t been tested recently
  • When you’re travelling and hooking up with new people
  • If you want extra confidence that you’re protected against HIV

PrEP is a safe and effective way to reduce the risk of HIV when it’s appropriate for someone’s health, risk factors, and preferences

Why many tops choose PrEP anyway

While bottoming carries a higher risk of HIV transmission, there are many tops who choose to take PrEP, too. 

Here are some of the main reasons that tops choose PrEP:

  • They have strong HIV protection across different sexual situations when PrEP is taken as prescribed.
  • They have added peace of mind, reducing any HIV-related anxiety surrounding sex.
  • They have an extra layer of protection beyond condoms.
  • Feel more confident dating or having sex with new partners, knowing they’ve added a strong layer of HIV protection

What if I usually use condoms?

Another factor to consider when you’re thinking about trying PrEP is how often you use condoms. 

Condoms are a key protective layer against HIV and other STIs. When used correctly and consistently, condoms reduce the risk of HIV and many other STIs, though they don’t eliminate STI risk completely.

If you’re using a condom every time you have sex, adding PrEP might seem like a layer you don’t need; when you’re using the condom correctly, your risk of HIV is much lower, though not zero.. 

But if the condom breaks or you forget to use one in the heat of the moment, there’s still a risk of transmission. Because of this, some tops choose to use both PrEP and condoms for peace of mind and backup protection, just in case. 

Talking to your clinician can help you determine what the right combination of condoms and PrEP is for you. That way, you can move forward knowing you’re approaching your sex life in a way that feels comfortable and safe.

Daily vs on-demand PrEP for tops

For tops who are taking PrEP, there are two different options you might have heard of:

  • Daily PrEP. This is the most common method of taking PrEP, with a dose taken around the same time each day.
  • PrEP on demand. Also known as 2-1-1 PrEP or event-based PrEP, this method involves protecting yourself with PrEP taken on a schedule before and after a planned sexual encounter. 

Daily PrEP is the most common option. It’s 99% effective at preventing HIV transmission, has minimal side effects, and can be taken safely long-term. 

Event-based PrEP, also called 2-1-1 PrEP, involves taking two pills before sex, followed by one pill 24 hours later and one more pill 48 hours after the first dose.

When taken correctly, event-based PrEP can be highly effective for some men who have sex with men who have anal sex.

Choosing the right PrEP option can be an overwhelming choice, especially if you’re considering using PrEP for the first time. This is another topic you can talk through with your clinician. They’ll discuss the differences between daily PrEP vs PrEP on demand, and help you determine what suits your needs and lifestyle best.

It’s important to note: 2-1-1 PrEP is not the right option for everyone. In the U.S., it is off-label and is only suitable for adult gay and bisexual men who have infrequent, planned anal sex.

How clinicians help tops decide

Getting PrEP comes with a lot to consider. The first step is talking with your clinician about what option is best for you. 

Here’s what tops can expect from an initial consultation:

  • A risk assessment: You’ll answer questions that will help your clinician determine your risk profile for HIV infection. 
  • Lifestyle questions: Your clinician will also make sure that PrEP fits into your lifestyle. For example, if you’re planning to go traveling and hook up soon, this might influence their recommendation.
  • Medication options: Then, you’ll talk through your options for PrEP medications, including injectable and oral PrEP. 
  • Testing requirements: Your clinician will order the labs you need before starting PrEP that make sure you’re HIV negative, check your kidney function, and test for other STIs. You’ll need HIV testing before starting PrEP and regular follow-up testing while you’re taking it. Based on your risk assessment, your HIV screening may be repeated 30 days after starting PrEP. Your clinician will also order renal function tests and STI screening before starting PrEP and during your follow-ups.
  • Insurance coverage and cost support: Finally, you’ll talk through your insurance options and determine how much PrEP will cost. (Many people end up being fully covered.)

If you still have questions about what taking PrEP means for you as a top, let your clinical team know. They’ll answer your questions, listen to your concerns, and give you the information you need to move forward with confidence.

How Freddie supports prevention without judgment

Prevention looks different for everyone, and it’s important you feel supported along the way.

At Freddie, we help tops decide what the best option is for their care without judgment, with discreet virtual care and support.

You’ll start by answering a few questions online, and making a virtual appointment with our team. This means you can access care in your own home, or wherever you feel most comfortable.

Our team of licensed clinicians are experienced in HIV prevention, providing an affirming path to accessing care that feels in line with what you need.

With Freddie, tops get practical guidance and support in a safe space — choosing the option that makes sense for you is personal, and we’re here to meet you where you are. 

Frequently asked questions

Do tops need PrEP?

Many tops choose to take PrEP to reduce their risk of contracting HIV, but it’s a personal choice. Talk with your clinician to decide if it’s the right option for you.

Is PrEP only for bottoms?

PrEP isn’t only for bottoms. Everyone who is at risk of HIV transmission can take PrEP.

While receptive anal intercourse (bottoming) carries a higher risk of HIV infection, insertive anal intercourse (topping) carries a moderate risk as well.

Can tops get HIV?

Yes, tops can get HIV. HIV can be transmitted from a bottom to a top, which is why some tops choose to take PrEP for additional prevention and peace of mind. Factors that increase tops’ risk of an HIV infection include their partner’s viral load, a recent infection, and whether they or their partner has an untreated STI.

Is topping lower risk for HIV?

Topping carries a lower risk for HIV than bottoming. However, studies have found that anal sex has the highest risk of transmission for HIV, whether you’re a top or a bottom. While the risk is lower, it still exists.

Should tops take PrEP if they use condoms?

For tops who use condoms, deciding to take PrEP is a personal decision. Condoms are highly effective at preventing the transmission of HIV and other STIs. 

Some tops still choose to take PrEP even while they use condoms. This helps to protect them from HIV infection if the condom breaks or is used incorrectly.

Why do some tops still use PrEP?

Some tops still use PrEP because, even though the risk is lower, you can still contract HIV when topping. It provides peace of mind and reduced anxiety during sexual encounters, and gives them extra confidence that they’re protected from HIV infection. 

Can tops use event-based PrEP?

Event-based PrEP is suitable for some men who have sex with men, but daily PrEP is more common. To determine which method of taking PrEP works best for what you need, discuss your options with your clinicians. 

How do I know if PrEP makes sense for me?

The best way to know if PrEP makes sense for you is to talk to your clinician or care team. They can work with you to determine if PrEP is a good choice for you, depending on your HIV risk and lifestyle.

Is daily PrEP worth it if I only top?

Taking daily PrEP is more common than event-based PrEP, and many tops take daily PrEP for ongoing protection and peace of mind. Your clinician will help you determine if daily PrEP makes the most sense for you.

Can I get PrEP online as a top?

Yes, you can get PrEP online from Freddie. You’ll start with a discreet virtual consultation with our team of clinicians. After your lab work is complete, your prescription will be delivered to your door.

Not sure if PrEP is right for you?

For tops considering PrEP, there isn’t a one-size-fits-all solution. Freddie can help you choose what fits your life. 

Book a free consultation with our clinicians to get started. We’ll answer your questions, talk through costs, and help you choose the right PrEP option for you.