Clinical considerations on the use of antiretrovirals and renal impairment.

INTRODUCTION

Advances in human immunodeficiency virus (HIV) treatment has significantly improved life expectancy, shifting mortality from HIV-related complications to non-HIV comorbidities, including renal impairment. As people living with HIV (PLWH) age, optimizing antiretroviral therapy (ART) in the setting of kidney dysfunction is essential in maintaining treatment efficacy while minimizing nephrotoxicity.

AREAS COVERED: A literature review was conducted using PubMed, Google Scholar, and ClinicalTrials.gov in early 2025. This review discusses the impact of renal impairment on ART selection, highlighting drugs requiring renal adjustments and those that remain unaffected. Nucleoside reverse transcriptase inhibitors (NRTIs), particularly tenofovir disoproxil fumarate (TDF), require careful monitoring, while integrase strand inhibitors (INSTIs) and non-nucleoside reverse transcriptase inhibitors (NNRTIs) are generally renally unaffected. Polypharmacy in aging PLWH further complicates treatment, increasing drug interaction risks and toxicity.

EXPERT OPINION: The aging PLWH population requires a shift in ART management to prevent renal dysfunction. Given the limitations of early kidney injury detection, and standardized renal dose adjustments, a more individualized approach is essential in caring for this population. Clinicians should prioritize renally safer alternatives, such as tenofovir alafenamide (TAF) over TDF, while ensuring adherence and addressing polypharmacy risk.