Standard anti-HIV treatment for people who are taking it for the first time will involve a combination, or "regimen," of three antiretrovirals.

see PDF file for table: Anti-HIV drug names

Preferred combination: Efavirenz (Sustiva) plus FTC and tenofovir (Truvada) OR 3TC and abacavir (Kivexa)

If you are starting anti-HIV treatment for the first time, you are recommended to take the non-nucleoside reverse transcriptase inhibitor (NNRTI) efavirenz with the nucleoside/nucleotide reverse transcriptase inhibitor (NRTI) combination pill Truvada (this contains FTC and tenofovir).

There is good evidence that efavirenz has a powerful and long-lasting anti-HIV effect. It also causes relatively few side-effects and is easy to take

But a major disadvantage of efavirenz is that it is easy for HIV to develop resistance to it which is why it is important to take it with two other drugs. It can also cause neurological side-effects. These normally only last a few weeks, some people find that symptoms such as headache, bad dreams, feeling disoriented and depression are longer-lasting and problematic.

You should not start treatment with efavirenz if you are thinking of becoming pregnant as there is a theoretical risk that it can cause birth-defects. If you are already taking efavirenz and become pregnant, you should contact your HIV clinic as soon as possible for advice.

Preferred NRTIs

There are two NRTI combination pills preferred for use in people starting treatment.

FTC (emtricitabine, Emtriva) and tenofovir (Viread) are combined in the pill Truvada. These drugs have a powerful and long-lasting anti-HIV effect and are easy to take.

There is some evidence linking tenofovir with an increased risk of kidney disease, particularly in people who have pre-existing kidney problems.

The alternative is Kivexa, a combined pill containing abacavir and 3TC.

About 5% - 8% of people who start treatment with abacavir experience a severe allergic or hypersensitive reaction. This has been linked to a particular gene called HLA B*5701 and you should have a test to see if you have this gene before starting treatment with abacavir. If your test is positive you should not take abacavir. If your test is negative it is unlikely that you will have a reaction to abacavir, but if you do develop symptoms including rash, tummy problems, sickness, and a feeling of being generally unwell soon after starting abacavir you should contact your HIV clinic as soon as possible.

Kivexa has a powerful and long-lasting anti-HIV effect and is easy to take. But there is some evidence that people with a high viral load are less likely to experience a fall in their viral load to undetectable levels if they take abacavir rather than tenofovir, so if you have a high viral load you shouldn't take it.

Abacavir has been linked in one big study with an increased risk of heart attack, particularly in people with existing factors for heart disease. But the results of this study are limited, not least because it did not examine the heart attack risk of either tenofovir or FTC.

Kivexa is recommended as an alternative to Truvada, particularly for people with kidney disease or a risk of kidney disease.

Combivir (AZT and 3TC) is not recommended for people starting anti-HIV treatment. This is because AZT has been associated with fat loss (lipoatrophy). But it might still be a good choice if you are pregnant or thinking of becoming pregnant. This is because there is good evidence AZT is good at preventing mother-to-child transmission of HIV.

Alternative combination: choice of NNRTI

The NNRTI nevirapine (Viramune) is an alternative to efavirenz, but it is only recommended for certain groups of people. These include women who wish to become pregnant, as there is good evidence that nevirapine is good at preventing mother-to-child transmission of HIV. Nevirapine might also be an option if you cannot tolerate the neurological side-effects of efavirenz.

Nevirapine can cause a rash and potentially dangerous liver side-effects. To reduce the risk of these, women should not start anti-HIV treatment with nevirapine if their CD4 cell count is above 250, and men should not start treatment with this drug if their CD4 cell count is above 400. 

 

Alternative combination: a boosted protease inhibitor

A boosted protease inhibitor (these protease inhibitors have their anti-HIV effect enhanced by taking them with a small dose of ritonavir) is an alternative to efavirenz.

Boosted protease inhibitors are recommended as an alternative to efavirenz if you:

• Are infected with HIV that is resistant to NNRTIs or NRTIs.
• Are pregnant or are thinking of becoming pregnant.
• Are unable to tolerate the neurological side-effects of efavirenz or have a history of depression.
• Are likely to find it difficult to take your HIV medicines properly. In these circumstances, there is less of a risk of resistance with a boosted protease inhibitor than with efavirenz.

The recommended boosted protease inhibitors are:

• Atazanavir (Reyataz) plus ritonavir.
• Darunavir (Prezista) plus ritonavir.
• Lopinavir/ritonavir (Kaletra). This is the only boosted protease inhibitor which includes ritonavir in the same pill.
• Fosamprenavir (Telzir) plus ritonavir.
• Saquinavir (Invirase) plus ritonavir.