Most commonly used first line combinations

Efavirenz (Sustiva, Stocrin)
Efavirenz is widely recommended as part of a first line therapy. It is one pill, oncedaily. Side effects, which can be significant, usually reduce after the first few weeks.

Main side effects are sleep disturbance (including nightmares), mood disturbance (including anxiety and depression) rash, liver toxicity and lipid changes. About 20% people switch to another drug over the first year.

Efavirenz should not be used during pregnancy or by women trying to conceive a baby.

Nevirapine (Viramune)
Nevirapine is an alternative to efavirenz, but has a small higher risk of serious side effects compared to efavirenz. Nevirapine is started at one tablet a day for the first two weeks, and then one tablet twice-daily.

Main side effects are rash and liver toxicity. These only occur in the first 6-8 weeks. Any low level rash should be taken seriously. Serious rash can be fatal. If you still have a rash after the first two weeks do not increase the dose but see your doctor.

Women with a CD4 count over 250 and men with a count over 400 should not start with nevirapine.

Lopinavir/r (Kaletra)
Kaletra is recommended as the preferred protease inhibitor. It is a twice-daily drug that includes ritonavir inside the same pill.

Main side effects are changes in lipids (blood fat), lipodystrophy (fat accumulation) which should be routinely monitored, and diarrhoea.

There is a low risk of resistance.

Atazanavir/r (Reyataz)
Atazanavir/r is not currently approved in Europe as first-line treatment, but it is still widely used, because it is dosed once-daily and generally easy to tolerate.

Main side effects are yellowing eyes or skin in 10% of patients, relating to increased levels of bilirubin. This is only a clinical problem when total bilirubin levels increase to 60-70 mmol/L. Lipids can increase due to the boosting dose of ritonavir.

Taken with a separate dose of ritonavir (/r), unless you have high drug levels.

Fosamprenavir/r (Telzir)
In studies fosamprenavir/r had similar results to Kaletra, but is less commonly used.

Side effects, including diarrhoea and lipids are similar to Kaletra.

Taken with a separate dose of ritonavir (/r).

Saquinavir/r (Invirase)
Saquinavir/r has shown similar results to Kaletra. There is less comparative data to Kaletra than for fosamprenavir/r.

Side effects, including diarrhoea and lipds are similar to Kaletra. May have a lesser effect on trigliceride levels.

Taken with a separate dose of ritonavir (/r).