Interactions between HIV medication and recreational drugs

When two drugs are taken at the same time, the way they interact with each other can have an effect on how they work and what side effects they cause. This is the case both for prescribed medicines and recreational (street) drugs.

There is much less research on the way medicines interact with recreational drugs than on the way medicines interact with other medicines.

We do know that some anti-HIV drugs and some recreational drugs are processed (metabolised) by the same pathways in the body. This can change the effect of one or both drugs when they are combined.

This applies to some, but not all anti-HIV drugs, and not all recreational drugs will interact with these HIV drugs.

However, recreational drugs are rarely sold in a pure form, so it’s hard to know what they contain. They may have been ‘cut’ with other substances and may contain larger or smaller amounts of the active ingredient than expected.

For this reason, it can be difficult to predict how recreational drugs will interact with HIV medications.

There are no known interactions between recreational drugs and pre-exposure prophylaxis (PrEP) pills or the PrEP injection called cabotegravir (Apretude). However, there are interactions with another PrEP injection called lenacapavir (Yeztugo). There is more information about lenacapavir further down this page.

Ritonavir and cobicistat

The two anti-HIV drugs most likely to be involved in harmful interactions with recreational drugs are ritonavir (Norvir) and cobicistat (Tybost).

Both of these are boosting agents, taken to boost levels of other antiretrovirals. Adding a small dose of one of these agents makes the liver break down the main drug more slowly, so that it stays in the body for longer or at higher levels. Without the boosting agent, the prescribed dose of the main drug wouldn’t work.

However, the boosting affect can also affect recreational drugs. This means the liver processes the recreational drug more slowly, and it stays in the body for longer, or in greater amounts. Sometimes this can cause serious side effects or an overdose.

If your HIV treatment includes a protease inhibitor, you are probably taking either ritonavir (Norvir) or cobicistat (Tybost). Protease inhibitors include:

• darunavir (Prezista)
• atazanavir (Reyataz)
• lopinavir (Kaletra).

Cobicistat is also taken with the integrase inhibitor elvitegravir (Vitekta). It is included in the combination pills:

• Stribild (with elvitegravir, tenofovir disoproxil and emtricitabine)
• Genvoya (with elvitegravir, tenofovir alafenamide and emtricitabine)
• Rezolsta (with darunavir)
• Evotaz (with atazanavir)
• Symtuza (with darunavir, tenofovir alafenamide and emtricitabine).

If you are not sure which medications you are taking, staff at your HIV clinic can tell you.

Taking recreational drugs with ritonavir or cobicistat

A dangerous interaction is possible between ritonavir or cobicistat and several recreational drugs.

• Cocaine (C, coke, rocks)
• GHB (G, Gina, liquid ecstasy, gamma-hydroxybutyrate) and also GBL, which works in a similar way
• Crystal methamphetamine (crystal meth, crystal, tina, meth, ice)
• MDMA (ecstasy, candy, X, mandy, molly)
• Mephedrone (meow meow, plant food, bath salts, MMC, M-CAT)
• Ketamine (K, vitamin K, special K, Kit Kat)
• Erectile dysfunction drugs (Viagra, Cialis, Levitra)
• Benzodiazepines (benzos, Valium, Xanax)
• Fentanyl (China White, Dance Fever, TNT)
• Nitazenes (pyro, Tony, oso), which are synthetic opioids
• LSD (acid, Lucy, dots, window, tab)
• PCP (angel dust, peace pills, hog).

An interaction may increase the intensity of the effect of the recreational drug, sometimes to unpleasant or dangerous levels. For example, you could pass out if you take GHB, GBL, or benzodiazepines with ritonavir or cobicistat.

There have been some cases of deaths and serious side effects in people taking ritonavir alongside crystal meth, MDMA, or ketamine.

Taking poppers with erectile dysfunction drugs can cause dangerous side effects such as a severe drop in blood pressure. These might be more likely if you are taking ritonavir or cobicistat.

Use of cannabis with ritonavir or cobicistat may increase the effects of cannabis. Using cannabis with atazanavir (Reyataz, also in the combination pill Evotaz) may decrease the levels of atazanavir in your system.

Non-nucleoside reverse transcriptase inhibitors (NNRTIs)

Taking cocaine with some non-nucleoside reverse transcriptase inhibitors (NNRTIs) may lead to higher levels of cocaine in your system. This applies to:

• efavirenz (Sustiva, also in Atripla)
• nevirapine (Viramune)
• etravirine (Intelence).

If you take cocaine with rilpivirine (Edurant) it can affect the way your heart beats.

Increased exposure to cannabis is reported when taken with etravirine (Intelence) and efavirenz (Sustiva, also in Atripla).

Efavirenz, etravirine, or nevirapine can lower levels of ketamine or any erectile dysfunction drugs you take. This can be a problem if you then take more than you usually would to get the same effect.

There are no known interactions between NNRTIs and GHB, MDMA, mephedrone, methamphetamine, or poppers.

Lenacapavir

A dangerous interaction is possible between lenacapavir and several recreational drugs.

• GHB (G, Gina, liquid ecstasy, gamma-hydroxybutyrate) and also GBL, which works in a similar way
• Ketamine (K, vitamin K, special K, Kit Kat)
• Erectile dysfunction drugs (Viagra, Cialis, Levitra)
• Benzodiazepines (benzos, Valium, Xanax)
• Fentanyl (China White, Dance Fever, TNT)
• Nitazenes, a type of synthetic opioids.

This is because lenacapavir increases your exposure to the recreational drug, making side effects and overdoses more likely.

Taking poppers with erectile dysfunction drugs can cause dangerous side effects such as a severe drop in blood pressure. This might be more likely if you are taking lenacapavir.

Recreational drugs without significant interactions

There are some recreational drugs which are thought to have a low potential for interacting with HIV medications. These include alcohol, poppers and nitrous oxide (laughing gas).

Anti-HIV medications without significant interactions

Several antiretroviral drugs are not thought to have problems with interactions. This the case for all nucleoside reverse transcriptase inhibitors (NRTIs), including the medications contained in PrEP pills (tenofovir disoproxil and emtricitabine, or tenofovir alafenamide and emtricitabine).

There are also no interactions with unboosted integrase inhibitors, in other words:

• dolutegravir (Tivicay, also in Triumeq, Dovato and Juluca)
• bictegravir (in the combination pill Biktarvy)
• raltegravir (Isentress) and
• Cabotegravir (but see the next paragraph).

Cabotegravir doesn’t have problems with interactions when it is taken on its own, for example when taken as Apretude for PrEP. However, in the combination of injections taken for HIV treatment (branded as Vocabria and Rekambys), it has a few interactions. This is because the injection also includes the NNRTI rilpivirine.

There are also no known interactions with:

• doravirine (Pifeltro, also in Delstrigo), a non-nucleoside reverse transcriptase inhibitor (NNRTI)
• maraviroc (Celsentri), a CCR5 inhibitor.

The University of Liverpool’s HIV Drug Interactions website (www.hiv-druginteractions.org) publishes a table summarising the likely interactions.

Practical advice

The first four weeks of taking a new set of HIV medications, when your body gets used to the new drugs, are likely to be the riskiest time for interactions.

Some interactions may have an effect after some time taking the drugs, while on other occasions they could have an effect the first time they are used.

If you use recreational drugs, or think you may in the future, talk to your HIV doctor or HIV pharmacist. They can give you a better understanding of the risks, based on your own situation.

Some things to consider are:

• The way drugs impact your sleeping patterns and routines: This can mean you might be more likely to miss doses of your HIV medications.
• Sexual situations: Drug use can affect your judgement about what is safe or appropriate. You may be more likely to put yourself or others at risk of hepatitis C, HIV, or other sexually transmitted infections.
• Injection equipment: If you inject drugs, it’s important not to share or re-use equipment with others (including water, swabs, filters, spoons and tourniquets).


If you are concerned about your drug use, there’s information and support available. You could start by talking to staff at your HIV clinic. If you don’t want to stop, or can’t stop, using recreational drugs, switching to HIV medications with less potential for interactions might be an option.

You can look for local support services on the FRANK website. In London, specialised services are available at the 56 Dean Street clinic and (for LGBT people) the Antidote drugs and alcohol service. Online services are available from Controlling Chemsex.

You can find more detailed information on recreational drugs, their short- and long-term impacts on physical and mental health, and their legal status on the FRANK website (www.talktofrank.com).

Image credit: Two syringes, powder and spoon on old wooden background. Image by Marco Verch. Available at Two syringes, powder and spoon on old wooden background - Creative Commons Images under a Creative Commons licence CC BY 2.0.