Recommended first-line treatments for HIV

Key points

  • The British HIV Association (BHIVA) provides guidelines for people starting HIV treatment for the first time.
  • There are several different options in the guidelines.
  • The choice of medication should be individualised, taking into account side-effects, other health issues, drug interactions and personal preferences.

If you are taking HIV treatment for the first time, guidelines from the British HIV Association (BHIVA) recommend a combination of three antiretroviral medications. This section summarises their guidelines, last updated in 2016.

The first two medications are sometimes called the ‘backbone’ of the HIV treatment combination. They are two drugs from the nucleoside/nucleotide reverse transcriptase inhibitor (NRTI) class.

For the backbone, most people are recommended to take tenofovir and emtricitabine. Tenofovir is available in two versions. The most commonly used is tenofovir disoproxil, while a newer version called tenofovir alafenamide is available. You may be offered the newer version if you have bone or kidney problems.

Tenofovir disoproxil and emtricitabine may be given together in a single combination tablet (available as a generic product, or as branded Truvada). Similarly, tenofovir alafenamide and emtricitabine are available in a combination tablet (Descovy). 

The backbone must be taken together with a third medication. There are several options:

  • 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). Atazanavir is also available in a combination tablet with the booster cobicistat (Evotaz).

or

  • darunavir (Prezista), boosted with ritonavir or cobicistat. Darunavir is a protease inhibitor. Darunavir is also available in the combination tablets Rezolsta or Symtuza.

or

  • dolutegravir (Tivicay). This is an integrase inhibitor. Dolutegravir is also available in the combination tablet Triumeq.

or

  • elvitegravir, boosted by cobicistat. This is an integrase inhibitor. Elvitegravir is only available in the combination tablets Stribild or Genvoya.

or

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

or

  • rilpivirine (Edurant). This is a non-nucleoside reverse transcriptase inhibitor. Rilpivirine is also available in the combination tablets Eviplera or Odefsey.

Glossary

boosting agent

Booster drugs are used to ‘boost’ the effects of protease inhibitors and some other antiretrovirals. Adding a small dose of a booster drug to an antiretroviral makes the liver break down the primary drug more slowly, which means that it stays in the body for longer times or at higher levels. Without the boosting agent, the prescribed dose of the primary drug would be ineffective.

association

An association means that there is a statistical relationship between two variables. For example, when A increases, B increases. An association means that the two variables change together, but it doesn't necessarily mean that A causes B. The relationship isn't necessarily causal.

reverse transcriptase

A retroviral enzyme which converts genetic material from RNA into DNA, an essential step in the lifecycle of HIV. Several classes of anti-HIV drugs interfere with this stage of HIV’s life cycle: nucleoside reverse transcriptase inhibitors and nucleotide reverse transcriptase inhibitors (NRTIs) and non-nucleoside reverse transcriptase inhibitors (NNRTIs). 

protease

An enzyme that HIV uses to break up large proteins into smaller ones from which new HIV particles can be made.

nucleoside

A precursor to a building block of DNA or RNA. Nucleosides must be chemically changed into nucleotides before they can be used to make DNA or RNA. 

You may be offered efavirenz as an alternative to one of these options if none are suitable for you. Efavirenz is a non-nucleoside reverse transcriptase inhibitor (NNRTI) and is available as a generic (non-branded) product.

As an alternative to the tenofovir and emtricitabine backbone, a combination of abacavir and lamivudine may be offered. You need to have a test before starting treatment with abacavir to see if you have a gene associated with allergy to abacavir (see Blood tests before starting or changing HIV treatment.) You must not take abacavir if you have this gene.

You may be offered abacavir and lamivudine in a combination tablet with dolutegravir (Triumeq).

 

Preferred

Alternative

NRTI backbone (choose one option)

tenofovir disoproxil/emtricitabine

tenofovir alafenamide/emtricitabine

abacavir/lamivudine

Third medication (choose one option)

atazanavir+ritonavir

darunavir+ritonavir

dolutegravir

elvitegravir/cobicistat

raltegravir

rilpivirine

efavirenz

 

Next review date