HIV and hemodialysis: Opportunity for use of single-tablet regimens

People living with HIV who are started on antiretroviral therapy are now living longer and enjoying a similar life expectancy as those who do not have HIV. As a result, people living with HIV are experiencing comorbidities commonly seen in an aging population. Chronic kidney disease (CKD) is one such comorbidity that may be encountered in people living with HIV, with some developing end-stage renal disease (ESRD) requiring hemodialysis.

When selecting an antiretroviral regimen, it is important to consider many different factors, including the potential for adverse effects and the dosing regimen considerations like the number of tablets and frequency of administration. In individuals with HIV and CKD, providers also should be mindful of the potential risk for nephrotoxicity, as well as the pharmacokinetic (PK) considerations of the antiretrovirals being considered as part of the patient’s antiretroviral regimen.

A complete antiretroviral regimen has a minimum of 2 active agents, and with the advent of single-tablet regimens, the goal would be to select a regimen that allows for single-tablet, once-daily dosing when feasible. For patients with CKD and ESRD, the potential to use a single-tablet regimen may be limited depending on their patients’ prior antiretrovirals, resistance mutations, and the degree of their CKD.

The Department of Health and Human Services provides some guidance to determine the most appropriate antiretrovirals for patients with CKD and ESRD. The guidelines recommend avoiding tenofovir disoproxil fumarate (TDF) in people with CKD defined as an estimated creatinine clearance (CrCl) less than 60 mL per minute due to the potential for proximal renal tubulopathy possibly leading to nephrotoxicity. In addition, the guidelines recommend using caution when prescribing antiretroviral regimens with TDF and the pharmacologic booster cobicistat, as studies have demonstrated a higher rate of renal toxicity with this combination.

Over the last several years, there have been several small case series and studies evaluating the use of selected single-tablet regimens in patients with ESRD on hemodialysis. The data supporting the use of these regimens are reviewed here.