Biktarvy is a common single-tablet regimen (STR) used for the treatment of HIV-1 infection, combining three potent antiretroviral drugs: bictegravir (an integrase strand transfer inhibitor), emtricitabine, and tenofovir alafenamide (both nucleoside reverse transcriptase inhibitors). While highly effective and widely used, patients may seek alternatives due to various reasons, including side effect concerns, specific co-existing conditions like hepatitis B, potential drug interactions, or a desire for different administration methods, such as long-acting injections. The landscape of HIV treatment offers several other FDA-approved options that are similarly effective, depending on individual patient needs. A detailed discussion with a healthcare provider is essential to determine the most suitable regimen.
Understanding the Need for Biktarvy Alternatives
There are several reasons why a patient might need to switch from or avoid Biktarvy as a first-line treatment. A few key factors include:
- Side Effects: While generally well-tolerated, Biktarvy can cause side effects such as nausea, diarrhea, headaches, and fatigue. Some patients experience undesirable side effect profiles that are better managed with a different regimen.
- Weight Gain: Recent studies have suggested that Biktarvy may be associated with more weight gain than certain alternative regimens, such as Dovato.
- Kidney or Bone Health Concerns: While Biktarvy's tenofovir component (TAF) is considered safer for the kidneys and bones than the older version (TDF), a provider may still recommend alternative options for patients with pre-existing kidney problems or bone density issues.
- Drug Interactions: Biktarvy has significant interactions with certain medications, including the antiarrhythmic drug dofetilide and the antibiotic rifampin, requiring its avoidance. It can also be less effective if taken incorrectly with certain antacids and mineral supplements.
- Co-infections: Biktarvy is effective against both HIV and hepatitis B (HBV) due to its components. Patients with HBV co-infection must remain on an HBV-active agent if they switch away from Biktarvy, or their hepatitis may worsen.
- Patient Preference: Some patients may prefer a regimen with fewer drugs, like Dovato, or a less frequent dosing schedule, such as an injectable, to reduce pill fatigue or simplify their routine.
Oral Single-Tablet Regimen (STR) Alternatives
For patients who prefer the convenience of a once-daily pill but need an alternative to Biktarvy, several STRs are available:
- Dovato (dolutegravir/lamivudine): A popular 2-drug STR, Dovato is non-inferior to 3-drug regimens like Biktarvy for maintaining viral suppression. It's a good choice for patients without prior resistance or co-infection with hepatitis B. Some studies show it may lead to less weight gain than Biktarvy.
- Triumeq (abacavir/dolutegravir/lamivudine): This 3-drug STR requires a genetic test ($HLA-B^*5701$) before starting to rule out a high risk of a severe hypersensitivity reaction. It is also not suitable for patients with HBV co-infection. It has comparable efficacy to Biktarvy.
- Genvoya (elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide): A 4-drug STR, Genvoya contains an integrase inhibitor (elvitegravir) boosted by cobicistat, along with the same two NRTIs as Biktarvy. While effective, Biktarvy's integrase inhibitor (bictegravir) may have a superior resistance profile.
- Delstrigo (doravirine/lamivudine/tenofovir disoproxil fumarate): Delstrigo is a 3-drug STR combining a non-nucleoside reverse transcriptase inhibitor (NNRTI) with two NRTIs. It uses the older form of tenofovir (TDF), which can have more renal and bone toxicity concerns than TAF.
- Juluca (dolutegravir/rilpivirine): A 2-drug STR, Juluca is only approved for patients who are already virologically suppressed and do not have hepatitis B.
Long-Acting Injectable Options
For those who prefer a less frequent dosing schedule, long-acting injectable options have become available:
- Cabenuva (cabotegravir/rilpivirine): Administered monthly or every two months by a healthcare provider, Cabenuva is an injectable regimen for virally suppressed patients. It offers an effective alternative for those who find daily pills a burden, but requires regular clinic visits and is not for those with active hepatitis B.
- Lenacapavir (Yeztugo): This is a newer-class long-acting injectable approved for PrEP (pre-exposure prophylaxis), with treatment applications under investigation. Given twice a year, it represents a significant advance in long-acting options.
Comparing Biktarvy Alternatives
| Feature | Biktarvy | Dovato | Triumeq | Cabenuva |
|---|---|---|---|---|
| Drug Components | Bictegravir, Emtricitabine, Tenofovir Alafenamide | Dolutegravir, Lamivudine | Dolutegravir, Abacavir, Lamivudine | Cabotegravir, Rilpivirine |
| Number of Drugs | 3 | 2 | 3 | 2 |
| Administration | Oral, once daily | Oral, once daily | Oral, once daily | Injectable, monthly or bimonthly |
| HBV Co-infection | Suitable (covers HBV) | Not suitable alone | Not suitable alone | Not suitable alone |
| Major Side Effects | Nausea, diarrhea, headache | Headache, weight gain | Hypersensitivity reaction (requires testing), insomnia | Injection site pain, fever |
| Key Caveat | Antacid interactions, potential for weight gain | Not for HBV, fewer drug interactions | Requires genetic testing ($HLA-B^*5701$), not for HBV | For virally suppressed patients only, requires clinic visits |
Considerations for Switching Treatment
Before changing from Biktarvy to an alternative, a doctor will consider several factors to ensure the new regimen is safe and effective:
Co-infections
For patients with co-existing hepatitis B, discontinuing a regimen with tenofovir (like Biktarvy) can lead to a severe flare-up of hepatitis B. Patients with HBV must transition to another regimen that also covers HBV or start additional medication to manage the hepatitis.
Drug Interactions
Certain drug interactions are specific to the components in each regimen. A healthcare provider will need a comprehensive list of all medications and supplements to check for potential issues. For instance, Biktarvy interacts with metformin and antacids, requiring timed dosing or alternative drug choices.
Patient History and Preferences
A patient's complete treatment history, including any resistance testing, informs the choice of a new regimen. Personal preferences regarding pill burden, dosing frequency, and side effect profiles also play a crucial role in improving adherence and quality of life. For some, the potential for less weight gain with Dovato is a significant benefit. For others, the convenience of a long-acting injectable like Cabenuva outweighs the need for clinic visits.
The Future of HIV Treatment
The development of long-acting antiretrovirals is a major frontier in HIV treatment. The recent FDA approval of lenacapavir for PrEP highlights the potential for future treatments with even less frequent dosing. This could lead to more patient-centric options and further simplify treatment, potentially moving beyond daily oral regimens entirely. These advances, combined with a greater understanding of patient-specific needs, will continue to evolve how HIV is managed.
Conclusion
While Biktarvy is a highly effective and popular single-tablet regimen for HIV treatment, it is not the only option. An array of alternatives exists, including other single-tablet regimens like Dovato and Triumeq, as well as innovative long-acting injectables like Cabenuva. The best choice is always a highly personalized decision, taking into account individual health status, co-infections, potential drug interactions, and lifestyle preferences. Patients should always consult with their healthcare provider to carefully weigh the pros and cons of switching regimens and ensure a seamless transition while maintaining viral suppression.
Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV
