Switching to Tenofovir/Lamivudine/Dolutegravir (TLD) Regimen

Introduction to TLD

The American College of Cardiology is not relevant here, however, the International Antiviral Society-USA recommends switching to TLD for patients with viral suppression on older regimens to reduce pill burden and minimize long-term toxicities, provided no documented NRTI or InSTI resistance mutations exist 2, 1

Before switching to TLD, a complete antiretroviral treatment history, including all prior regimens and duration of use, must be reviewed to identify any previous treatment failures, according to the International Antiviral Society-USA and other guidelines 2, 1
All prior resistance testing results, including genotypic and phenotypic tests if available, must be reviewed to ensure no integrase strand transfer inhibitor (InSTI) or nucleoside reverse transcriptase inhibitor (NRTI) resistance mutations are present, as recommended by the International Antiviral Society-USA and other guidelines 2, 1
Current viral suppression status must be confirmed with HIV-1 RNA <50 copies/mL if switching from a suppressive regimen, as stated in the guidelines from the International Antiviral Society-USA 1
Hepatitis B virus (HBV) co-infection status must be assessed because if HBV-positive, tenofovir-containing regimens are mandatory to maintain HBV suppression, according to the International Antiviral Society-USA and other guidelines 2, 1
Renal function assessment, including estimated glomerular filtration rate (eGFR), must be performed to determine whether TAF or TDF formulation is appropriate, as recommended by the guidelines from the International Antiviral Society-USA 1

Tenofovir alafenamide (TAF) is preferred over tenofovir disoproxil fumarate (TDF) for most patients due to reduced renal and bone toxicity, as stated in the guidelines from the International Antiviral Society-USA and other guidelines 1
The International Antiviral Society-USA recommends using TAF/lamivudine/dolutegravir for patients with or at risk for kidney disease (eGFR <60 mL/min/1.73 m²) or bone disease (osteopenia/osteoporosis) 2, 1

For pregnant patients or those planning pregnancy, dolutegravir with TAF/lamivudine is the recommended regimen with high antiviral efficacy and low rates of adverse birth outcomes, according to the guidelines from the International Antiviral Society-USA and other guidelines 1
For tuberculosis co-infection, dolutegravir dosing must be increased to 50 mg twice daily during active tuberculosis treatment with rifampin to overcome drug interactions, as recommended by the International Antiviral Society-USA and other guidelines 3, 1
For HBV co-infection, patients must receive a regimen containing two drugs active against HBV—typically tenofovir (TAF or TDF) plus lamivudine—and should generally not be switched to 2-drug ART regimens, according to the International Antiviral Society-USA and other guidelines 2, 1

After switching to TLD, HIV-1 RNA should be monitored at 1 month to confirm maintained or achieved viral suppression, as recommended by the International Antiviral Society-USA and other guidelines 2, 1
HIV-1 RNA should be monitored every 3 months for the first year, then at least every 6 months if stable, according to the guidelines from the International Antiviral Society-USA and other guidelines 2, 1
Renal function monitoring, including serum creatinine and eGFR, should be performed, particularly if using TDF, as stated in the guidelines from the International Antiviral Society-USA 1
Bone density assessment should be performed if risk factors are present and TDF is used, according to the guidelines from the International Antiviral Society-USA 1
Adherence support should be provided as transition from other regimens may require counseling, as recommended by the guidelines from the International Antiviral Society-USA 1

Switching to TLD without reviewing complete resistance testing history may compromise efficacy and lead to treatment failure, as warned by the International Antiviral Society-USA and other guidelines 1
Using TLD in patients with documented integrase resistance without expert consultation is not recommended, as stated in the guidelines from the International Antiviral Society-USA and other guidelines 2
Switching to TLD if eGFR <30 mL/min/1.73 m² without dose adjustment of individual components should be avoided, according to the guidelines from the International Antiviral Society-USA 1