Antiretroviral Therapy for Treatment-Naive Patients with Renal Impairment and Drug Resistance

Rationale for Regimen Selection

The American College of Physicians recommends against using bictegravir/TAF/emtricitabine in patients with NRTI mutations, as it may have reduced activity 1, 2, 3
The International AIDS Society recommends against using dolutegravir-based regimens in patients with NRTI resistance mutations, as they rely on fully active NRTI backbones for optimal efficacy 2, 3
The presence of multiple NRTI resistance mutations can compromise the activity of tenofovir and emtricitabine, according to the World Health Organization 2

The European AIDS Clinical Society recommends using darunavir, which has a high genetic barrier to resistance and maintains activity even when NRTI resistance is present 2, 1
Boosted darunavir plus TAF/emtricitabine is specifically recommended when InSTI resistance is suspected or when NRTI mutations are present, according to the US Department of Health and Human Services 1

The National Kidney Foundation recommends against using TDF in individuals with or at risk for kidney disease, due to its potential for renal toxicity 2, 3
TAF has fewer renal and bone toxicities compared to TDF, especially when used with pharmacological boosters like cobicistat or ritonavir, according to the American College of Cardiology 1

The British HIV Association recommends using darunavir 800 mg/ritonavir 100 mg once daily plus TAF/emtricitabine as an alternative regimen 2, 3
The Infectious Diseases Society of America recommends against using NNRTI-based regimens in patients with multiple NNRTI resistance mutations, such as K103N 2

The Centers for Disease Control and Prevention recommend confirming resistance testing results and reviewing for any additional mutations 5
The American Association for the Study of Liver Diseases recommends assessing for hepatitis B co-infection, as this would require maintaining TAF or TDF in the regimen 1
The International AIDS Society recommends measuring HIV RNA at 4-6 weeks to assess initial virologic response, and continuing viral load monitoring every 3 months until suppression is achieved 1