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Concomitant use of direct-acting antiviral agents for HCV infection and antiretroviral agents

	Sofosbuvir	Ledipasvir	Velpatasvir	Glecaprevir-pibrentasvir	Elbasvir-grazoprevir	Voxilaprevir	Daclatasvir
Bictegravir	✓	✓	✓	✓*	✓	✓	✓
Dolutegravir	✓	✓	✓	✓	✓	✓	✓
Cabotegravir	✓	✓	✓	✓	✓	✓	✓
Elvitegravir (cobicistat boosted)	✓	Caution when used with TDF^¶	Caution when used with TDF^¶	✓^Δ	Not recommended	Caution when used with TDF^¶^◊	✓
Raltegravir	✓	✓	✓	✓	✓	✓	✓
Rilpivirine	✓	✓	✓	✓	✓	✓	✓
Efavirenz	✓	✓	Not recommended	Not recommended	Not recommended	Not recommended	Caution: increase daclatasvir to 90 mg daily
Doravirine	✓	✓	✓	✓	✓	✓	✓
Darunavir (boosted)	✓	Caution when used with TDF^¶	Caution when used with TDF^¶	Not recommended	Not recommended	Caution when used with TDF^¶^◊	✓
Atazanavir (boosted)	✓	Caution when used with TDF^¶	Caution when used with TDF^¶	Not recommended	Not recommended	Not recommended	Caution: decrease daclatasvir to 30 mg daily
Other agents that are contraindicated or not recommended	Tipranavir	Tipranavir	Etravirine Nevirapine Tipranavir	Etravirine Tipranavir	Etravirine Nevirapine Lopinavir-ritonavir Tipranavir Fostemsavir^§	Etravirine^◊ Nevirapine Tipranavir^◊	Tipranavir
Other potential concerns or caution		Renal monitoring when used with TDF regimens^¶	Renal monitoring when used with TDF regimens^¶		Caution with maraviroc	Renal monitoring when used with TDF regimens^¶^◊ Caution with fostemsavir^§	Caution with etravirine: increase daclatasvir to 90 mg daily

The checkmark indicates that the HCV antiviral and the antiretroviral agent can be coadministered safely. Abacavir-lamivudine and TAF-emtricitabine can be used with all acceptable combinations above. Caution with TDF-containing regimens is indicated in the table. Some of these combinations have not been studied directly, but their safety or potential interactions are extrapolated from known pharmacokinetics.

TAF: tenofovir alafenamide; TDF: tenofovir disoproxil fumarate; DAA: direct-acting antiviral.
* The European product label for bictegravir-emtricitabine-tenofovir alafenamide notes caution when used with glecaprevir-pibrentasvir, because levels of bictegravir may be elevated with coadministration.
¶ Coadministration of ledipasvir or velpatasvir with TDF results in elevated levels of tenofovir, particularly when ritonavir-boosted protease inhibitors or cobicistat-containing regimens are also used. In contrast, coadministration of TAF with ledipasvir or velpatasvir does not result in elevated levels of tenofovir. If ledipasvir or velpatasvir is to be used in a patient taking a TDF-containing regimen, we switch the TDF to TAF, if possible. If that switch is not possible and no other HCV regimen can be used, we check a baseline creatinine, urinalysis, and phosphate level and monitor for tenofovir-associated renal toxicity (eg, with creatinine and phosphate at least monthly) while on HCV therapy.
Δ Glecaprevir and pibrentasvir levels are elevated in this setting. Although the elevations do not appear to be clinically relevant, monitoring for hepatic toxicity (eg, checking transaminases every 4 weeks) is suggested.
◊ Contraindication or caution is warranted with these drugs because of the potential interactions with sofosbuvir and/or velpatasvir, with which voxilaprevir is coformulated.
§ The active metabolite of fostemsavir (temsavir) may increase plasma concentrations of grazoprevir and voxilaprevir through inhibition of OATP1B1/3. If possible, other DAA regimens are recommended for individuals taking fostemsavir.

References:

AASLD-IDSA. Recommendations for testing, managing, and treating hepatitis C. http://www.hcvguidelines.org. Accessed on November 30, 2021.
University of Liverpool. HEP Drug Interactions. https://www.hep-druginteractions.org/checker. Accessed on November 30, 2021.

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