Date of report 17 Mar 2026

Reported case interaction between
Bictegravir and Hypericum perforatum

The use of over-the-counter medications is common in the general population, including among people living with HIV. This case reinforces the importance of actively assessing the use of non-prescribed therapies.

Hyperforin, a key component of St John’s wort (Hypericum perforatum), is an inducer of CYP3A, UGT1A1, and P-glycoprotein (P-gp), and can therefore reduce plasma concentrations of bictegravir and tenofovir alafenamide, potentially leading to loss of virological efficacy. Although low-dose preparations of St John’s wort containing less than 1 mg of hyperforin per day may pose a lower risk of drug–drug interactions, ensuring consistent use of such low-dose formulations is often not feasible, and would require close virological monitoring. Therefore, coadministration of BIC/FTC/TAF and St John’s wort should generally be avoided.

In this case, virological rebound occurred during concomitant use of St John’s wort, with re-suppression achieved following its discontinuation. This highlights the clinical relevance of this interaction.

Finally, this case underscores the importance of selecting antiretroviral regimens with a high genetic barrier to resistance, particularly in situations where the use of over-the-counter medications or herbal supplements is suspected.