HAART Regimens Compatible with Rifampin

Primary Recommended Regimens

• The American Medical Association recommends dolutegravir 50 mg twice daily (not once daily) plus tenofovir/emtricitabine or lamivudine for patients requiring rifampin therapy 1, 2
• The American Medical Association recommends efavirenz 600 mg daily plus two NRTIs for patients requiring rifampin therapy 1, 2, 3
• Dolutegravir must be dosed at 50 mg twice daily (not the standard once-daily dose) when co-administered with rifampin for active tuberculosis treatment 1, 2, 3
• Combine dolutegravir with tenofovir alafenamide (TAF) or tenofovir disoproxil fumarate (TDF) plus emtricitabine (FTC) or lamivudine (3TC) as the NRTI backbone 1, 2
• Efavirenz 600 mg once daily can be used without dose adjustment when combined with rifampin 1, 2, 3
• Pair efavirenz with two NRTIs (tenofovir plus emtricitabine or lamivudine) 1, 2

Important Considerations for Tenofovir Alafenamide

• TAF has a pharmacokinetic interaction with rifampin that reduces TAF levels, though clinical data are limited 1, 2
• If using TAF with rifampin, close monitoring of HIV RNA levels is essential 1, 2
• TDF may be the safer tenofovir option when rifampin is required 1

Alternative Option (Third-Line)

• Ritonavir-boosted protease inhibitor regimens should only be used if dolutegravir and efavirenz are not options 1, 2, 3
• Requires substituting rifabutin 150 mg daily for rifampin (not using rifampin itself) 1, 2, 3
• Combine boosted PI with tenofovir/emtricitabine or lamivudine 1, 2

Regimens That Are Contraindicated with Rifampin

• The following HAART regimens cannot be used with rifampin due to severe drug-drug interactions: Bictegravir/TAF/FTC, dolutegravir/lamivudine (2-drug regimen), darunavir boosted with ritonavir or cobicistat, doravirine, elvitegravir/cobicistat combinations, long-acting cabotegravir plus rilpivirine, and rilpivirine-containing regimens 1, 2, 3

Special Situations

• For 3HP regimen (weekly rifapentine plus isoniazid for 12 weeks): dolutegravir 50 mg once daily is adequate 1, 2
• For 1HP regimen (daily rifapentine plus isoniazid for 1 month): dolutegravir 50 mg twice daily is required 1, 2

Critical Timing Considerations

• Rifampin's enzyme induction reaches maximum effect within 1 week of starting therapy 4

Common Pitfalls to Avoid

• Never use standard once-daily dolutegravir dosing with rifampin - this will result in subtherapeutic levels and treatment failure 1, 2
• Do not assume all integrase inhibitors behave similarly - bictegravir cannot be used with rifampin while dolutegravir (at increased dose) can 1, 2, 3
• Rifabutin is not interchangeable with rifampin for first-line tuberculosis treatment - rifabutin is only used when protease inhibitors are absolutely necessary 1, 2