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HIV Antiretroviral Side Effect Management

Recognition and management of antiretroviral therapy adverse effects

Written by: Saygı Hospital Health Guide Editorial Board
Last updated:

This content has been compiled by the Saygı Hospital Health Guide Editorial Board and is periodically reviewed by a specialist physician.

References (5)

This content is for informational purposes only and does not constitute medical advice. You can book an appointment at our Internal Medicine department. Book Appointment →

What is HIV Antiretroviral Side Effect Management?

Antiretroviral therapy (ART) for HIV consists of integrase strand transfer inhibitors (INSTI: dolutegravir, bictegravir, raltegravir), nucleoside reverse transcriptase inhibitors (NRTI: tenofovir alafenamide, tenofovir disoproxil, abacavir, emtricitabine, lamivudine), non-nucleoside reverse transcriptase inhibitors (NNRTI: efavirenz, rilpivirine, doravirine), and protease inhibitors (PI: darunavir, atazanavir, lopinavir).

Modern preferred regimens (INSTI-based) have minimal toxicity, but recognized adverse effects include weight gain (dolutegravir, bictegravir), insomnia and neuropsychiatric symptoms (dolutegravir, efavirenz), nephrotoxicity and bone density loss (tenofovir disoproxil more than tenofovir alafenamide), HLA-B*57:01-related hypersensitivity (abacavir), QT prolongation (rilpivirine), bilirubin elevation (atazanavir), and gastrointestinal intolerance (PIs).

Management requires baseline screening (HLA-B*57:01 before abacavir, hepatitis B and C, renal and hepatic function, fasting lipids, bone density in older or risk patients), routine monitoring, and individualized regimen optimization. Drug-drug interactions, particularly with antacids, polyvalent cations, anticonvulsants, and certain statins, require pharmacist input. Resistance testing guides switching when virologic failure occurs.

Symptoms

Weight gain (especially dolutegravir, bictegravir)
Insomnia, vivid dreams (efavirenz, dolutegravir)
Depression, anxiety, suicidal ideation (efavirenz)
Headache
Gastrointestinal symptoms (nausea, diarrhea)
Fatigue
Rash
Hyperpigmentation
Lipohypertrophy or lipoatrophy (older drugs)
Hyperlipidemia
Insulin resistance, type 2 diabetes
Renal dysfunction (tenofovir DF)
Bone density loss, osteoporosis
Hepatotoxicity
Hyperbilirubinemia (atazanavir)
QT prolongation (rilpivirine)
Hypersensitivity reaction (abacavir HLA-B*57:01)
Lactic acidosis (older NRTIs, rare)
Peripheral neuropathy (older NRTIs)
Pancreatitis (didanosine, historical)

Risk Factors

Older age
Hepatitis B or C coinfection
Chronic kidney disease
Diabetes mellitus, metabolic syndrome
Pre-existing cardiovascular disease
Pre-existing osteoporosis or low bone density
Pre-existing depression or anxiety
HLA-B*57:01 positive (abacavir)
Female sex (some toxicity higher)
Body mass index extremes
Concomitant nephrotoxic medications
Concomitant hepatotoxic medications
Polypharmacy and drug interactions
Adherence challenges
Substance use
Pregnancy (regimen-specific considerations)
Tuberculosis coinfection (rifamycin interactions)

When to See a Doctor?

If you experience any of the following symptoms, seek medical attention promptly:

  • New rash on ART (especially within first 6 weeks)
  • Symptoms of hypersensitivity (fever, malaise, GI symptoms on abacavir)
  • Significant weight gain (over 10% body weight)
  • Insomnia, mood changes, suicidal thoughts
  • Persistent gastrointestinal symptoms
  • New muscle weakness, peripheral neuropathy
  • Jaundice, abdominal pain (hepatotoxicity)
  • Decreased urine output, swelling (renal dysfunction)
  • Bone pain, fragility fracture
  • Palpitations or syncope (QT prolongation)
  • Difficulty taking medications consistently
  • Pregnancy planning or pregnancy
  • New medication initiation (drug interactions)
  • Treatment fatigue or wishing to switch regimens
  • Routine HIV care visits (every 3-6 months)

Treatment Methods

01
Comprehensive baseline evaluation including CBC, comprehensive metabolic panel, fasting lipids, glucose, HbA1c, hepatitis B and C screening, renal function (creatinine, urinalysis), urine protein-to-creatinine ratio
02
HLA-B*57:01 testing before abacavir initiation
03
Tuberculosis screening (interferon-gamma release assay, chest imaging)
04
Bone density assessment in older or at-risk patients
05
Cardiovascular risk assessment
06
Pregnancy testing in women of childbearing age
07
Individualized regimen selection based on resistance, comorbidities, drug interactions
08
INSTI-based first-line regimens preferred (dolutegravir/abacavir/lamivudine, bictegravir/tenofovir alafenamide/emtricitabine, dolutegravir/lamivudine)
09
Avoid abacavir if HLA-B*57:01 positive
10
Tenofovir alafenamide preferred over tenofovir disoproxil for renal and bone safety
11
Routine monitoring at 2-4 weeks, 3 months, 6 months, then every 6 months
12
Adherence counseling and support
13
Mental health screening and management
14
Lipid management with statins (consider drug interactions)
15
Weight management, lifestyle modification, GLP-1 agonists for ART-associated obesity
16
Renal monitoring with creatinine, urinalysis, urine protein-to-creatinine ratio
17
Hepatic monitoring with ALT, AST, bilirubin
18
Bone health: vitamin D, calcium, weight-bearing exercise, bisphosphonates if osteoporosis
19
Switch regimen for adverse effects when alternatives available
20
Resistance testing if virologic failure (HIV RNA detectable on consistent therapy)
21
Drug interaction review by pharmacy
22
Vaccinations (pneumococcal, influenza, hepatitis A and B, HPV, COVID-19)
23
Cancer screening per guidelines
24
Coordinated multidisciplinary care including infectious disease, primary care, mental health

Which Department to Visit?

You can visit our Enfeksiyon Hastalıkları department for these complaints. Our specialist physicians will create the most suitable treatment plan for you.

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Health Disclaimer: The information on this page is prepared for general informational purposes only. It does not replace medical diagnosis and treatment. Please consult your physician for your complaints. Saygı Hospital does not accept responsibility for actions taken based on the information on this page.