Biktarvy and Levonorgestrel Interactions
Biktarvy (bictegravir/emtricitabine/tenofovir alafenamide) does not have clinically significant interactions with levonorgestrel-based contraceptives and can be used safely together without dose adjustments or additional contraceptive methods.
Evidence for No Significant Interaction
The available evidence strongly supports the safety of combining Biktarvy with levonorgestrel:
Tenofovir/emtricitabine (two of the three components in Biktarvy) showed no pharmacokinetic interactions with levonorgestrel. A study demonstrated that concomitant oral tenofovir/emtricitabine use was not associated with changes in plasma levonorgestrel concentrations among women using levonorgestrel implants in the first year of use 1.
Nucleoside reverse transcriptase inhibitors (NRTIs), which include tenofovir and emtricitabine, do not have clinically significant interactions with hormonal contraceptive methods 1. Specifically, tenofovir showed no effect on ethinyl estradiol or norgestimate levels 1.
Bictegravir, as an integrase strand transfer inhibitor (INSTI), belongs to a drug class that generally does not interact with hormonal contraceptives. The evidence indicates that integrase inhibitors have minimal drug-drug interactions compared to older antiretroviral classes 2.
Contrast with Other Antiretrovirals
It's important to distinguish Biktarvy from antiretrovirals that DO interact with levonorgestrel:
Efavirenz (an NNRTI) significantly decreases levonorgestrel levels and may compromise contraceptive efficacy in women using levonorgestrel implants or emergency contraception, with documented contraceptive failures 1.
Ritonavir-boosted protease inhibitors decrease contraceptive hormone levels and require alternative or additional contraceptive methods 1.
Nevirapine does not significantly interact with levonorgestrel based on subsequent studies that refuted initial concerns 1.
Clinical Recommendations
For patients taking Biktarvy with any levonorgestrel-based contraceptive (pills, implants, IUDs, or emergency contraception):
- No dose adjustments are needed for either medication 1
- No additional contraceptive methods are required for pregnancy prevention
- Dual protection (condoms plus hormonal contraception) should still be recommended to prevent sexually transmitted infections and HIV transmission to partners 1
Important Caveats
- The evidence base for Biktarvy specifically is limited, but the individual components (tenofovir/emtricitabine) have well-established safety data with levonorgestrel 1
- Bictegravir has a high genetic barrier to resistance and minimal drug-drug interactions, making it suitable for combination with hormonal contraceptives 2
- Always counsel patients that hormonal contraceptives do not protect against STIs, and barrier methods remain essential for HIV-positive individuals 1