Twice-daily bictegravir during rifampicin-based tuberculosis therapy: A pragmatic alternative

HIV-tuberculosis coinfection remains a major global health challenge and the concomitant use of antiretroviral therapy with rifampicin-based tuberculosis treatment is frequently complicated by clinically relevant drug-drug interactions. Rifampicin strongly induces CYP3A4 and UGT1A1 enzymes, leading to significant reductions in plasma concentrations of several integrase strand transfer inhibitors, including bictegravir. As a result, recommended strategies usually involve modifying antiretroviral therapy to rifampicin-compatible regimens such as dolutegravir administered twice daily or using rifabutin-based tuberculosis therapy. However, these alternatives may not always be feasible or well tolerated in routine clinical practice. Increasing pharmacokinetic understanding of bictegravir and emerging clinical data suggest that dose intensification may partially overcome rifampicin-induced reductions in drug exposure. In this letter, we explore the potential role of bictegravir/emtricitabine/tenofovir alafenamide administered twice daily during rifampicin-based tuberculosis treatment as a pragmatic option in selected patients when standard therapeutic approaches cannot be used.