When
you discuss starting HIV treatment with your healthcare team, they will talk to
you about the known side-effects of each drug. Make sure you tell them about
any concerns you have; they should take these into account in helping you choose
the most suitable treatment combination for you.
In
the UK, if you are starting HIV treatment for the first time, the recommended
treatment is a combination of three drugs. The treatment guidelines recommend
that, for most people, this includes tenofovir and emtricitabine (Truvada). These drugs are from the nucleoside/nucleotide
reverse transcriptase inhibitor (NRTI) class and would be taken with one of the
following as a third drug in the combination:
- atazanavir (Reyataz).
This is a drug from the protease inhibitor class. It has its anti-HIV
effect boosted by taking it with a small dose of a second protease
inhibitor called ritonavir (Norvir).
or
- darunavir (Prezista),
boosted with ritonavir. Darunavir is also a protease inhibitor.
or
- dolutegravir (Tivicay). Dolutegravir is an integrase inhibitor.
or
- elvitegravir,
boosted by cobicistat (Stribild). This is an integrase inhibitor.
or
- raltegravir (Isentress).
This is an integrase inhibitor.
or
- rilpivirine (Edurant). This is a non-nucleoside
reverse transcriptase inhibitor (NNRTI).
For
some people, efavirenz (Sustiva) will be a suitable third drug in the
combination, but this is less commonly used nowadays. This is an NNRTI. An
alternative to tenofovir and emtricitabine would be abacavir and lamivudine.
Cost
permitting, you may be offered your treatment in a single pill, once a day:
- Tenofovir disoproxil, emtricitabine
and rilpivirine are available in a fixed-dose combination tablet called Eviplera.
- Dolutegravir, abacavir and
lamivudine come in a fixed-dose combination tablet called Triumeq.
- Odefsey is a fixed-dose
tablet combining rilpivirine, emtricitabine and tenofovir alafenamide.
- Stribild is a
fixed-dose tablet combining elvitegravir, emtricitabine and tenofovir
disoproxil, along with cobicistat.
- Genvoya is a
fixed-dose tablet combining elvitegravir, cobicistat, emtricitabine
and tenofovir alafenamide.
- Tenofovir disoproxil, emtricitabine
and efavirenz are available in a fixed-dose combination tablet called Atripla.
You
can find out more about these drugs in the NAM booklet Anti-HIV drugs.
Although
these drugs are very effective and generally safe, they can still cause
side-effects. Details of these are provided below. You can find more information
on the most common side-effects in the section Common side-effects.
Truvada (emtricitabine and tenofovir disoproxil)
Both
drugs in Truvada are usually well
tolerated. But they can cause diarrhoea, nausea and vomiting. Other very common or common
side-effects of both are headache, stomach pain, dizziness, rash and a feeling of weakness.
Other
common side-effects of emtricitabine include insomnia (difficulty sleeping) and abnormal dreams, neutropenia (lowered white
blood cells), raised liver and pancreatic enzymes, raised levels of the enzyme
creatine kinase, heartburn, raised blood sugar and
triglycerides (blood fats), and an allergic reaction. Emtricitabine can cause
changes in the colour of the skin, particularly in people of non-white race.
You should talk to your doctor if this happens to discuss your treatment
options. An uncommon side-effect of emtricitabine is anaemia.
Other common side-effects of tenofovir include flatulence, low blood
phosphate levels, raised liver enzymes, tiredness and bloating.
Kidney problems can be a rare side-effect of
tenofovir, particularly for people who are taking other medicines that affect
the kidneys, or for those who have other risk factors for kidney disease, such
as high blood pressure or diabetes. Your regular HIV monitoring will include
tests to check the health of your kidneys.
More
rarely, there is a long-term risk of developing bone problems as a result of
treatment with tenofovir. Your regular HIV monitoring will include blood tests
to check levels of minerals to make sure that you are not at risk of this
side-effect.
There
is now a newer formulation of tenofovir (tenofovir alafenamide, or TAF), which
may be suitable for people with bone or kidney issues, or people who
experienced bone or kidney problems with tenofovir disoproxil (TDF). There is a
fixed-dose combination of emtricitabine and TAF available, called Descovy.
Liver problems are a rare side-effect of tenofovir,
including hepatitis (liver inflammation).
Atazanavir (Reyataz)
Generally, people tolerate atazanavir well.
Very common or common side-effects: Nausea, diarrhoea, rash, abdominal pain, headache, vomiting, heartburn
and tiredness.
A common side-effect of atazanavir is hyperbilirubinaemia,
or raised bilirubin levels. Bilirubin is a waste product produced by the liver during
the breakdown of old red blood cells. If levels of
bilirubin increase this can cause jaundice – yellowing of the skin and whites
of the eyes. This is not dangerous, but some people find it distressing.
Talk to your doctor at your routine HIV clinic
appointment if you notice a yellowing of your skin or eyes. However, if there
is yellowing, and you also feel sick, vomit, have diarrhoea, have stomach pain,
or feel generally unwell, you should see a doctor immediately. These could be signs
of liver inflammation (hepatitis), which needs immediate monitoring and
treatment.
Uncommon or rare side-effects: Kidney stones,
gallstones, depression, anxiety, weight gain or loss and changes in appetite,
muscle weakness, abnormal liver function, changes in heart rhythm. If you
have an existing heart condition, or are on other treatments that can affect
heart function, your heart function will be regularly monitored. Rarely,
atazanavir can cause a hypersensitivity (allergic) reaction, including a severe
rash called Stevens Johnson syndrome. If you develop a rash with other
symptoms, such as a fever, seek medical advice.
Atazanavir
is not recommended for people with reduced kidney function who need dialysis.
Your doctor will test your kidney function before prescribing it, but it is
important to tell them about any kidney problems you have or have had in the past.
Unlike some other anti-HIV drugs, atazanavir is less
likely to increase lipid (blood fat) levels, so may be a good option for people
with high cholesterol or other risk factors for heart disease.
Darunavir (Prezista)
Generally, people tolerate darunavir well. It's
important it's taken with food.
Very common or common side-effects: Diarrhoea, vomiting, nausea, abdominal pain, increased blood amylase, heartburn,
flatulence, bloating, headache, peripheral neuropathy (damage to the nerves of
the hands and/or feet), dizziness, insomnia (difficulty
sleeping), raised lipid levels, diabetes, raised liver and
pancreatic enzymes, a
feeling of loss of strength, tiredness, rash. A rash
is more likely if it is taken in combination with raltegravir.
Uncommon
side-effects, rare or very rare side-effects:
Abnormal liver function, abnormal kidney function, changes in heart rhythm,
changes in blood count, changes in appetite, gout (a build-up of uric acid
crystals in the joints), depression, disturbed sleep.
Rarely,
darunavir can cause a hypersensitivity (allergic) reaction, including a severe
rash called Stevens Johnson syndrome. If you develop a rash with other
symptoms, such as a fever, seek medical advice.
Dolutegravir (Tivicay, also in Triumeq)
Generally, dolutegravir causes relatively few
side-effects compared to other anti-HIV drugs. However, some people have had to
stop treatment with it because of side-effects affecting the central nervous
system. These are more common in women, people over 60 and people starting
abacavir at the same time as dolutegravir.
Very common or common side-effects: Nausea,
diarrhoea, headache, rash, itching, vomiting, stomach pain, insomnia (difficulty
sleeping), dizziness, abnormal dreams, fatigue (tiredness), flatulence,
increase in liver enzymes, increase in creatine phosphokinase (enzymes produced
in the muscles).
Uncommon
side-effects, rare or very rare side-effects:
Hepatitis, severe depression. Rarely, dolutegravir can cause a hypersensitivity
(allergic) reaction. If you develop a rash with other symptoms, such as a
fever, seek medical advice.
Elvitegrevir (Vitekta, also in Genvoya, Stribild)
Generally, people tolerate elvitegravir well. It's important it's taken
with food.
Common side-effects: Stomach pain,
vomiting, rash, headache, diarrhoea, nausea, fatigue (tiredness).
Uncommon and rare side-effects
include:
Insomnia (difficulty sleeping), problems with digestion (dyspepsia), feeling
bloated, flatulence, dizziness, tingling, abnormal taste. Depression and
suicidal thoughts are also uncommon side-effects, affecting people who have
pre-existing mental health problems.
Raltegravir (Isentress)
Generally, people tolerate raltegravir well.
Very common and common side-effects: Decreased appetite, headache, insomnia (difficulty sleeping), abnormal
dreams, depression, dizziness, vertigo (feeling that you are spinning, or your
surroundings are moving), bloating, stomach pain,
flatulence, nausea, vomiting, diarrhoea, indigestion, rash, weakness and
restlessness, tiredness, fever, raised liver and pancreatic enzymes, raised
blood fats (these side-effects would be identified through routine blood tests).
Uncommon side-effects: Dry mouth, shingles, anaemia (low
red blood cells) and changes in blood count, iron deficiency, mood changes,
disturbed sleep, changes in vision, abnormal kidney function, hepatitis.
In uncommon cases, raltegravir has been known to
cause a hypersensitivity (allergic) reaction, including a severe rash called
Stevens Johnson syndrome. If you develop a rash with other symptoms, such as a
fever, seek medical advice.
Unlike some other anti-HIV drugs, raltegravir is
less likely to increase lipid (blood fat) levels, so may be a good option for
people with high cholesterol or other risk factors for heart disease.
Rilpivirine (Edurant, also in Eviplera)
Generally, people tolerate rilpivirine well. It’s
important it’s taken with food.
Very common or common
side-effects:
Insomnia (difficulty sleeping), tiredness,
drowsiness, headache, nausea, rash, changes in liver and pancreas function,
changes in blood counts, increases in blood fats (cholesterol and
triglycerides), lack of appetite, depression, dizziness, stomach ache, vomiting,
dry mouth.
Efavirenz (Sustiva)
Many people have side-effects in the first few weeks
of taking efavirenz, but these often go away fairly quickly.
Very common or common side-effects: Rash, dizziness, headache, diarrhoea, nausea,
vomiting, tiredness, stomach ache, raised triglycerides (blood fats), raised liver enzymes.
Efavirenz
can cause a feeling of being ‘out of sorts’, confusion, impaired concentration,
sleep disturbance and abnormal dreams. Mental health problems including
depression, anxiety and low mood have also been reported as side-effects of
efavirenz.
These
side-effects are often most noticeable in the first few weeks after treatment
with efavirenz is started and then lessen or even go away completely. However,
a small number of people experience longer-term or more serious sleep and mood
problems due to treatment with efavirenz and some people need to stop taking
the drug because of these.
If
you do experience side-effects caused by efavirenz, discuss these with your
doctor. There may be a number of options available to you to help reduce these
side-effects. One simple step you can take is to avoid taking efavirenz with a
high-fat meal as this will increase the level of the drug in your body and can
increase the side-effects. You could do this by taking it on an empty stomach
or at least two hours after food. Taking it an hour or so before bed means that
the drug level should be highest while you are asleep.
If
you have a history of mental health problems, efavirenz might not be a good
choice of treatment and you may want to talk about other treatment options with
your doctor.
Uncommon side-effects: Liver problems, pancreatitis. An uncommon side-effect of
efavirenz is a hypersensitivity (allergic) reaction, including a severe rash
called Stevens Johnson syndrome. If you develop a rash with other symptoms,
such as a fever, seek medical advice.
Rarely,
people experience serious mental health problems such as psychosis or delusions;
this seems to be more likely if you have had mental health issues in the past.
If you are worried about your mood or behaviour, bear in mind changes in these
could be linked to efavirenz. Talk to your doctor about your concerns.