No, PrEP is not only for bottoms. It is approved and recommended for anyone at risk of HIV exposure, regardless of sexual position, gender, or the type of sex they have. That includes insertive partners (tops), people who have vaginal sex, and people who share injection equipment. The CDC’s current clinical guidance is straightforward: prescribe PrEP to anyone who asks for it, including sexually active people who do not report specific HIV risk factors.
Why the Misconception Exists
The idea that PrEP is “only for bottoms” likely comes from the significant difference in HIV risk between receptive and insertive anal sex. The receptive partner faces a risk of roughly 1 in 72 per act with an HIV-positive partner (when no condoms, PrEP, or treatment is involved). For the insertive partner, that number drops to about 1 in 909 per act. That’s a meaningful gap, and it’s led some people to conclude that tops don’t really need PrEP.
But lower risk is not zero risk. A 1 in 909 chance per act accumulates over time, especially with multiple partners or inconsistent condom use. And in practice, many people don’t stick exclusively to one role. Even someone who identifies primarily as a top may occasionally be receptive, and a single encounter at higher risk can matter.
How PrEP Works in the Body
PrEP medications work by building up protective drug concentrations in the tissues where HIV enters the body. The active compounds accumulate in immune cells in the blood, rectal tissue, and vaginal tissue, blocking the virus from establishing an infection if exposure occurs.
For the insertive partner during anal sex, HIV can enter through the mucous membrane of the urethra or through any small breaks in skin. PrEP protects against this by maintaining drug levels in the bloodstream and immune cells throughout the body. You don’t need to be the receptive partner for the medication to have tissue to protect.
One important detail: the medication reaches protective levels at different speeds depending on the tissue involved. Rectal tissue concentrations build up relatively quickly, while vaginal tissue and blood compartments take longer. For vaginal sex and injection drug use, PrEP pills need about 21 days of daily use to reach maximum protection. This timeline matters for anyone starting PrEP, not just receptive partners.
Who PrEP Is Actually For
The CDC recommends PrEP for all people at risk of HIV through sex or injection drug use. There is no mention of sexual role in the eligibility criteria. The groups who benefit include:
- Gay and bisexual men in any sexual role, top, bottom, or versatile
- Heterosexual men and women who have partners with HIV or whose partners’ status is unknown
- Transgender men and women
- People who inject drugs and may share equipment
- Anyone with a recent sexually transmitted infection, which signals ongoing exposure risk
If you’re sexually active and want protection against HIV, you qualify. The clinical guidance explicitly states that providers should prescribe PrEP to anyone who requests it.
PrEP Options Available
There are currently three FDA-approved PrEP options, and understanding the differences matters depending on your situation.
Truvada (and its generics) is a daily pill approved for all adults at risk of HIV, regardless of gender or type of sexual exposure. It’s the most broadly studied and covers receptive anal sex, insertive anal sex, vaginal sex, and injection drug use.
Descovy is another daily pill, but it has a narrower approval. It was not studied in cisgender women for vaginal sex exposure because the drug showed very low concentrations in vaginal tissue during testing. If your primary risk comes from receptive vaginal sex, Truvada or the injectable option are better choices.
Apretude (cabotegravir) is an injectable form of PrEP given every two months after an initial loading period. In clinical trials involving cisgender men and transgender women who have sex with men, it showed a 66% reduction in HIV risk compared to daily oral PrEP with Truvada, meaning it outperformed an already effective medication. The injectable option removes the need to remember a daily pill, which can improve real-world effectiveness.
Effectiveness Depends on Adherence
PrEP is highly effective, but only when taken as prescribed. If you skip doses or take the medication inconsistently, protective drug levels in your blood and tissues can drop below what’s needed to block the virus. This applies equally whether you’re a top, bottom, or versatile.
For daily oral PrEP, consistent use is critical. There is no FDA-approved on-demand or event-based dosing schedule in the United States. Some international guidelines do allow a “2-1-1” schedule (two pills before sex, one pill the next day, one pill the day after) for men who have anal sex only, but this is not part of current U.S. prescribing guidelines. The only approved approach is daily use as prescribed.
For the injectable option, staying on schedule with your every-two-month injections is the equivalent of daily adherence. Missing or delaying an injection can leave gaps in protection.
The Bottom Line on Risk
Being a top lowers your per-act risk compared to being a bottom, but it doesn’t eliminate it. Over a year of regular sexual activity with partners whose HIV status you may not know, that 1-in-909 chance per act can add up to a real cumulative risk. PrEP closes that gap for insertive partners just as it does for receptive ones. Your sexual position doesn’t determine whether you’re a candidate for PrEP. Your exposure to HIV does, and that exposure exists for tops, bottoms, and everyone in between.