Which antiretroviral regimen should be avoided in a patient with food insecurity who cannot reliably take their medication with food?

Emtricitabine/Rilpivirine/Tenofovir Alafenamide Should Be Avoided in Food-Insecure Patients

The correct answer is B) Emtricitabine/rilpivirine/tenofovir alafenamide, as rilpivirine must be taken with food for adequate absorption and is the only regimen among these options with a strict food requirement. 1, 2

Food Requirements by Regimen

Regimens That Can Be Taken Without Food (Safe for Food-Insecure Patients)

• Bitegravir/emtricitabine/tenofovir alafenamide (Option A): Can be taken with or without food 2
• Abacavir/dolutegravir/lamivudine (Option C): Can be taken with or without food 1, 2
• Efavirenz/emtricitabine/tenofovir disoproxil fumarate (Option D): Should actually be taken on an empty stomach for maximum benefit, making it suitable for food-insecure patients 3, 2

Regimen That REQUIRES Food (Avoid in Food Insecurity)

• Emtricitabine/rilpivirine/tenofovir alafenamide (Option B): Rilpivirine requires stomach acidity and must be taken with food for adequate absorption 1, 2

Clinical Evidence Supporting This Recommendation

Food-insecure patients prescribed antiretrovirals requiring food experience significantly worse outcomes. Research demonstrates that among food-insecure individuals, those taking ART requiring food had lower CD4 cell counts, poorer HIV suppression, and worse treatment adherence compared to those on regimens without food requirements 4, 5

Key Findings from Research

• 63% of HIV patients experience food insecurity, and 57% of these patients are prescribed regimens requiring food 4
• Food-insecure patients on food-requiring regimens show poorer viral suppression and lower adherence rates 5
• The association between food insecurity and medication nonadherence is partially mediated by food insecurity stigma and depression 6

Practical Algorithm for Regimen Selection in Food Insecurity

When screening reveals food insecurity 1:

1. First-line choice: Bictegravir/emtricitabine/tenofovir alafenamide (Option A) - no food requirement, high barrier to resistance, once-daily dosing 1

2. Alternative: Abacavir/dolutegravir/lamivudine (Option C) - no food requirement, but requires HLA-B*5701 testing before use 1

3. Avoid: Any rilpivirine-containing regimen (Option B) - strict food requirement makes it inappropriate 1, 2

4. Consider: Efavirenz-based regimens (Option D) if other options unavailable, though higher CNS side effects 1, 3

Common Pitfalls to Avoid

• Do not assume all modern single-tablet regimens have similar food requirements - rilpivirine is the critical exception requiring food 2
• Do not prescribe rilpivirine to patients with baseline HIV RNA >100,000 copies/mL or CD4 <200/μL regardless of food security 1
• Do not overlook screening for food insecurity - guidelines explicitly recommend addressing food insecurity as part of comprehensive HIV care 1
• Do not forget HLA-B*5701 testing before prescribing abacavir-containing regimens to avoid life-threatening hypersensitivity reactions 1