Back to contents

HIV treatment combinations and their side-effects

The likelihood of having a side-effect

Side-effects are often described in the following categories:

  • very common. This means that more than one in ten people taking the medicine are likely to have the side-effect.
  • common. This means that between one in ten and one in 100 people are affected.
  • uncommon. This means that between one in 100 and one in 1000 people are affected.
  • rare. This means that between one in 1000 and one in 10,000 people are affected.
  • very rare. This means that fewer than one in 10,000 people are affected.
  • not known. This means that it’s not been possible to estimate the number of people affected.

In this booklet, we list the very common or common side-effects for individual drugs. We have only included the uncommon, rare or very rare side-effects if they are potentially dangerous.

Starting treatment for the first time?

The drugs recommended for people starting HIV treatment for the first time generally have few side-effects. It is particularly good to know that they do not cause the more serious side-effects that were caused by some of the older HIV drugs – these drugs are now only used rarely because other drugs are now available that are safer and often easier to take.

Because of this, it’s less common than it used to be for people to have to change their HIV treatment because of side-effects. Many people will probably be able to take the currently available first-choice anti-HIV drugs safely for decades. However, some people do change treatment because of side-effects, so your healthcare team will be used to discussing these sorts of problems and looking at alternative drug choices.

Remember, if you experience any side-effects, mention them at your clinic. If a side-effect persists, it’s nearly always possible to do something about it.

You can find out more about the guidelines for HIV treatment for adults in our summaries of the 2012 guidelines, produced by NAM for BHIVA: www.aidsmap.com/uk-treatment-guidelines

Recommended first HIV treatment combination

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.

If you are starting HIV treatment for the first time, the recommended treatment is a combination tablet (currently known as Truvada), which contains two drugs:

  • tenofovir, a nucleotide reverse transcriptase inhibitor (NtRTI)

and

  • FTC (emtricitabine),a nucleoside reverse transcriptase inhibitor (NRTI)

taken with one of the following drugs as a third drug in the combination:

  • atazanavir (Reyataz), boosted with ritonavir. 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.

or

  • darunavir (Prezista), boosted with ritonavir. Darunavir is also a protease inhibitor.

or

  • efavirenz (Sustiva). This is a non-nucleoside reverse transcriptase inhibitor (NNRTI).

or

  • raltegravir (Isentress). This is an integrase inhibitor.

Tenofovir, FTC and efavirenz are also 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 (FTC and tenofovir)

Both drugs in Truvada are usually well tolerated. But they can cause diarrhoea, nausea (feeling sick) and vomiting (being sick). See the Common side-effects section for more information on dealing with these. 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 FTC include insomnia and abnormal dreams, neutropenia (lowered white blood cells), raised liver and pancreatic enzymes, raised creatine kinase levels, heartburn, raised blood sugar and triglycerides (blood fats), and an allergic reaction. FTC can cause changes in the colour of the skin (known as hyperbilirubinaemia), particularly in people of non-white race. You should talk to your doctor if this happens to discuss your treatment options.

Other common side-effects of tenofovir include flatulence, low blood phosphate levels, increased transaminases, 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.

Uncommon side-effect of FTC: Anaemia.

Like other NRTIs, rarely, tenofovir can cause lactic acidosis.

Atazanavir (Reyataz)

Generally, people tolerate atazanavir well.

Very common or common side-effects: Nausea, diarrhoea, rash, stomach ache, headache, insomnia, vomiting, heartburn, tiredness, lipodystrophy, diabetes.

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, 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. See Hypersensitivity (allergic) reactions for more information and 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.

Very common or common side-effects: Diarrhoea, vomiting, nausea, stomach ache, increased blood amylase, heartburn, bloating, headache, peripheral neuropathy, dizziness, insomnia, lipodystrophy, 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. 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. See Hypersensitivity (allergic) reactions for more information and advice. 

Side-effects seem to be less common and less severe in people who take darunavir once a day compared to twice-daily dosing.

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, 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 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. See Hypersensitivity (allergic) reactions for more information and 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.

Raltegravir (Isentress)

Generally, people tolerate raltegravir well.

Very common and common side-effects:Decreased appetite, headache, insomnia, abnormal dreams, dizziness, vertigo, bloating, stomach ache, flatulence, nausea, vomiting, diarrhoea, rash, muscle weakness, tiredness, fever, raised liver and pancreatic enzymes, raised blood fats.

Uncommon side-effects: Extreme thirst (polydipsia).

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. See Hypersensitivity (allergic) reactions for more information and 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.

Other options if you are starting treatment

Your doctor may suggest you start treatment on a different drug combination to the ones described above.

There may be reasons why one of the combinations recommended for starting HIV treatment is not suitable for you. This could be because of possible interactions with other drugs you are taking, or because the type of HIV you have is resistant to one or more drugs. Or it could be because you want to avoid certain side-effects.

In some cases, if your doctor thinks it will work as well for you, they may suggest you start on a combination that costs less for the NHS to buy. Your doctor will only do this if they also think this combination will work for you.

There are some alternative combinations recommended for people starting HIV treatment.

An alternative to Truvada is the combination drug Kivexa (3TC and abacavir).

Alternative choices for a third drug in the combination are:

  • Kaletra, the protease inhibitor lopinavir, boosted with ritonavir, taken in two pills containing the combined drugs

or

  • nevirapine (Viramune, Viramune prolonged-release), a drug in the NNRTI class

or

  • rilpivirine (Edurant). This is the latest drug in the NNRTI class

or

  • fosamprenavir (Telzir), also a protease inhibitor that needs to be boosted with ritonavir.

Truvada and rilpivirine are also available in a fixed-dose combination tablet called Eviplera.

You can find out more about these drugs in the NAM booklet, Anti-HIV drugs.

Although these drugs are effective and generally safe, they can still cause side-effects. Details of these are provided below. You can find more information in the section on Common side-effects.

Kivexa (3TC and abacavir)

Generally, people tolerate Kivexa well.

Very rarely, abacavir 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. See Hypersensitivity (allergic) reactions for more information and advice.

Some (but not all) research has linked abacavir to an increased risk of heart attack, particularly for people who have other risk factors for heart disease. Because of this, abacavir is not recommended for people who have risk factors for heart disease, if a suitable alternative is available.

Both abacavir and 3TC can cause rash, fever, tiredness, headache, nausea, vomiting and diarrhoea. These side-effects are usually quite mild and lessen or go away completely after a few weeks of treatment. Your doctor can also give you other medicines to control some of these side-effects if you need them. See the Common side-effects section for more information on how to manage these.

Other very common or common side-effects of 3TC include cough, nasal symptoms, stomach ache, hair loss, insomnia and joint pain.

Another common side-effect of abacavir is loss of appetite.

Rare side-effects of 3TC:Liver damage (hepatitis). Very rarely, pancreatitis.

Like other NRTIs, rarely, abacavir and 3TC cause lactic acidosis.

Kaletra (lopinavir/ritonavir)

Very common or common side-effects: Respiratory tract infections (infections of the sinuses, throat, airways or lungs), skin infections, diabetes, swollen glands, anaemia and other blood changes, anxiety, dizziness, insomnia, headache, nausea, vomiting, diarrhoea, stomach ache and bloating, tiredness, weakness, muscle pain, heartburn, rash, raised liver enzymes and liver toxicity, lipodystrophy, erectile dysfunction, menstrual changes (heavy periods or missing periods).

Kaletra is not recommended for people with increased risk for heart disease as it can cause increases in lipids (blood fats) and high blood pressure. Your regular HIV monitoring will include tests to measure levels of blood fats (cholesterol and triglycerides). See the section on Longer term side-effects for more information on managing this sort of side-effect.

Kaletra can cause pancreatitis. This nearly always occurs in people who have had it before, or who are on other medication that can cause pancreatitis.

Rare side-effects: Changes in heart rhythm.

Nevirapine (Viramune, Viramune prolonged-release)

To reduce the risk of an allergic reaction to nevirapine, you should not start treatment with nevirapine if you have a detectable viral load and, for men, a CD4 cell count above 400 or, for women, a CD4 cell count of more than 250. If you have an undetectable viral load, you can start treatment with nevirapine but your liver function will be carefully monitored.

The main side-effect of nevirapine is rash. To reduce the risk of this, for the first two weeks of treatment the dose of nevirapine is 200mg once daily, after which it is increased to 200mg twice daily. Nevirapine prolonged-release is taken as a 400mg dose once a day after the first two weeks of treatment.

For most people, the rash is not serious, and clears up. A small number of people need to change treatment because of the rash the nevirapine can cause, and a very small number of people require hospitalisation because of this rash.

Other very common or common side-effects include headache, nausea, vomiting, stomach ache, diarrhoea, fever, tiredness, raised liver enzymes. Nevirapine can cause serious liver toxicity. See Hypersensitivity (allergic) reactions for more information and advice.

Other uncommon or rare side-effects: Raised blood pressure, anaemia. Uncommonly, nevirapine can cause a severe rash called Stevens Johnson syndrome. If you develop a rash with other symptoms, such as a fever, seek medical advice. See Hypersensitivity (allergic) reactions for more information and advice.

Rilpivirine (Edurant, also available in the combination drug Eviplera)

Generally, people tolerate rilpivirine well. It’s important it’s taken with food.

Very common or common side-effects: Insomnia, 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.

Rare side-effects: At doses above 25mg, changes in heart rhythm (known as QT prolongation).

Fosamprenavir (Telzir)

Very common or common side-effects: Nausea, vomiting, diarrhoea, rash, abdominal pain, headache, dizziness, tiredness, tingling around the mouth, raised liver and pancreas enzymes, lipodystrophy, diabetes.

Fosamprenavir is not recommended for people with increased risk for heart disease as it can cause increases in lipids (blood fats). Your regular HIV monitoring will include tests to measure levels of blood fats (cholesterol and triglycerides). See the section on Longer-term side-effects for more information on managing this sort of side-effect.

Rarely, fosamprenavir can cause a severe rash called Stevens Johnson syndrome. If you develop a rash with other symptoms, such as a fever, seek medical advice. See Hypersensitivity (allergic) reactions for more information and advice.

Drugs not recommended for first-line HIV treatment

Some drugs are no longer recommended for standard HIV treatment in the UK. These include d4T (stavudine, Zerit) and ddI (didanosine, Videx), because of the serious and long-term side-effects they can cause, such as peripheral neuropathy and fat loss or gain (lipodystrophy). There is more information on these later in this booklet.

Other drugs are no longer recommended for people starting HIV treatment or changing to a new treatment, although there may be people who are already on these drugs and happy to continue with them. These include the protease inhibitor saquinavir (Invirase).

HIV treatment during pregnancy

If you have conceived when already on treatment, you can usually stay on your current combination of drugs, if these are successfully suppressing your viral load. If you are pregnant and need treatment for your own health, you should start on one of the combinations recommended in the British HIV Association (BHIVA) treatment guidelines for adults.

Many pregnant women have morning sickness – nausea (feeling sick) and vomiting (being sick) – in the first three months of pregnancy. If you are less than 12 weeks pregnant, and your CD4 count is around 350, you and your doctor could discuss waiting to start HIV treatment until morning sickness stops (usually at about 13 to 14 weeks). This is because some anti-HIV drugs can also make you feel sick during the first few weeks of treatment.

Otherwise, you should start HIV treatment by week 24 of your pregnancy, at the latest. The combination used will depend on a range of factors.

AZT (zidovudine, Retrovir) is not recommended for people starting treatment for their own health, but is still sometimes used as a short-term treatment to prevent mother-to-child transmission during pregnancy and birth. This is because there is good evidence that AZT is a safe and effective drug to use in preventing mother-to-child transmission.

Although AZT is the only drug licensed for use during pregnancy, it is now known that other drug combinations are effective in preventing mother-to-child transmission. So your treatment combination may or may not include AZT.

You can find out more about HIV treatment during pregnancy in the booklet in this series, HIV & women and you can get personalised information using our online tool HIV & pregnancy: www.aidsmap.com/pregnancy. You can find out more about the guidelines for HIV treatment during pregnancy in our summaries of the 2012 guidelines, produced by NAM for BHIVA: www.aidsmap.com/uk-treatment-guidelines

AZT (zidovudine, Retrovir)

Very common and common side-effects: Nausea, vomiting, tiredness, headache, dizziness, stomach ache, muscle pain, feeling unwell, changes in blood counts, raised liver enzymes.

Rare side-effects: Liver toxicity, lipoatrophy (see Longer-term side-effects), lactic acidosis.

Changing treatment because of side-effects

In some circumstances you may need or want to change treatment because of side-effects. This is more likely to be an option if you have little or no resistance to anti-HIV drugs and your viral load is undetectable. Then you should be able to stop the drug that is causing your side-effect and switch to a different treatment.

Changing treatment can be more complex if you have a detectable viral load or you have HIV that is resistant to some anti-HIV drugs. Your doctor will look at the results of resistance tests and discuss possible treatment options with you. Having resistance will, however, limit the number of replacement drugs that are available to you.

It also makes good sense to ask about the possible side-effects of the drugs you are considering switching to.

Treatment for people who have taken a lot of anti-HIV drugs in the past

A number of anti-HIV drugs are now available that provide very important treatment options for people who have taken a lot of HIV treatment in the past, particularly those with drug-resistant virus.

These drugs are particularly effective against HIV because they work against the virus in a slightly different way to the older anti-HIV drugs, or work against virus resistant to other drugs in the same drug class. These drugs are:

  • T-20 (enfuvirtide, Fuzeon)
  • maraviroc (Celsentri)
  • raltegravir (Isentress, also used by people starting treatment for the first time)
  • etravirine (Intelence)
  • tipranavir (Aptivus).

T-20 (enfuvirtide, Fuzeon)

This is currently the only anti-HIV drug that is given by injection, and is now only prescribed in very rare and specific situations. The key side-effects are pain and a hardening of the skin at the site of the injection. These are often called injection-site reactions. If you need to take T-20, you’ll be given information about how to inject it and how to reduce the risk of injection-site reactions developing.

Other very common or common side-effects include infections such as sinusitis, flu and pneumonia, decreased appetite, peripheral neuropathy (see Longer-term side-effects) and pancreatitis.

T-20 has some rarer side-effects as well, including a hypersensitivity reaction. Your doctor should explain these side-effects to you, and what action to take, before you start treatment with it.

Maraviroc (Celsentri)

Generally, people tolerate maraviroc well.

Very common and common side-effects: Nausea, diarrhoea, tiredness, headache, depression, insomnia, loss of appetite, stomach ache, rash, raised liver enzymes, weakness, anaemia.

Uncommon, rare and very rare side-effects: Liver problems, kidney problems, angina, cancers.

Rarely, maraviroc can cause a severe rash called Stevens Johnson syndrome, and very rarely serious liver toxicity. If you develop a rash with other symptoms, such as a fever, seek medical advice. See Hypersensitivity (allergic) reactions for more information and advice.

If you also have hepatitis B or hepatitis C, or have any other liver problems, your doctor should monitor you carefully and do blood tests to check the health of your liver.

Raltegravir (Isentress)

See Recommended first HIV treatment combination earlier in this section.

Etravirine (Intelence)

Generally, people tolerate etravirine well.

Very common or common side-effects: Rash, diarrhoea, headache, nausea, vomiting, reflux, stomach ache, anxiety, night sweats, insomnia, tiredness, raised lipids (cholesterol and triglycerides), diabetes, changes to blood counts, high blood pressure, peripheral neuropathy (see Longer-term side-effects), kidney failure, heart attack.

Uncommon, rare and very rare side-effects: Liver problems, pancreatitis.

There is a risk of developing a hypersensitivity (allergic) reaction in the form of a severe rash (Stevens Johnson syndrome). See Hypersensitivity (allergic) reactions for more information on this.

Tipranavir (Aptivus)

This drug is now very rarely used.

Very common and common side-effects: Nausea, diarrhoea, vomiting, bloating, stomach ache, heartburn, tiredness, headache, raised lipids (cholesterol and triglycerides), flatulence, rash.

Rare side-effects: Bleeding in brain, liver toxicity, peripheral neuropathy (see Longer-term side-effects), pancreatitis.

Side-effects

Published July 2013

Last reviewed July 2013

Next review July 2016

Contact NAM to find out more about the scientific research and information used to produce this booklet.

This content was checked for accuracy at the time it was written. It may have been superseded by more recent developments. NAM recommends checking whether this is the most current information when making decisions that may affect your health.