Older HIV treatment had a bad reputation for side effects, and some of that worry still hangs around. Modern treatment is very different. US treatment guidelines note that in trials of the newer medicines, fewer than 1 in 10 people starting treatment had side effects serious enough to stop or change it1.
That does not mean no side effects. This guide explains what is common on the most used pills, what usually settles, and the longer-term effects your clinic keeps an eye on. For the first weeks on dolutegravir, see our guide to your first 90 days.
Common side effects of Biktarvy, Dovato and Triumeq
| Medicine | Most common side effects in the US label | Also listed as common in the European leaflet |
|---|---|---|
| Biktarvy | Diarrhoea, nausea, headache2 | Abnormal dreams, tiredness, weight gain5 |
| Dovato | Headache, nausea, diarrhoea, difficulty sleeping, tiredness, anxiety3 | Abnormal dreams, weight gain6 |
| Triumeq | Difficulty sleeping, headache, tiredness4 | Abnormal dreams, weight gain7 |
Most of these are mild. In the main Biktarvy trials, the large majority of side effects were rated grade 1, the mildest level2. Stomach upset and headache are most likely in the first weeks and often fade as the body gets used to the medicine.
One early effect is worth knowing about. When treatment starts and the immune system recovers, it can react to infections that were hiding in the body, causing fever or swelling for a while. This is called immune reconstitution syndrome. It affects people who already had a hidden infection when they started treatment, and your clinic will look into any new symptoms in the first months2.
Mood, sleep and dreams
Efavirenz (in Atripla and many generic combinations) is the HIV medicine best known for this. In trials, about half of the people taking it had nervous system symptoms such as dizziness, trouble sleeping, poor concentration and vivid dreams. These usually start in the first day or two and generally ease after the first 2 to 4 weeks. Taking it at bedtime on an empty stomach helps. Serious mood problems, including severe depression, were reported more often than with other medicines8.
Integrase inhibitors (dolutegravir, bictegravir) cause these problems less often, but difficulty sleeping and abnormal dreams are listed as common for Dovato and Triumeq37. If sleep is a problem, ask whether changing the time of day you take your tablet could help.
Depression and suicidal thoughts have been reported with several HIV medicines, mostly in people who already had depression or another mental health condition23. Tell your team about any mental health history before you start, and get help straight away if your mood drops or you have thoughts of harming yourself.
Heart and cholesterol
People with HIV have a higher risk of heart disease, so this matters. Two points come up most:
- Abacavir (in Triumeq). Some observational studies linked it with a higher risk of heart attack. Combined analyses of randomised trials did not find that extra risk, and the US label calls the evidence inconclusive. As a precaution, the label advises considering a person’s heart risk and reducing the risks that can be changed, such as high blood pressure, high cholesterol, diabetes and smoking4.
- Blood fats. Cholesterol and triglycerides can rise on some regimens. Raised cholesterol was a common lab finding in the darunavir trials, for example11, and the European leaflets for Biktarvy, Dovato and Triumeq all note that blood fats and blood sugar may rise during HIV treatment567.
US guidelines say raised cholesterol on treatment can be handled either by switching the medicine likely to be causing it or with a cholesterol medicine such as a statin1. Some statins interact with boosted HIV regimens; see our statin comparison and our guide to HIV medicine interactions.
Bones
The older form of tenofovir, tenofovir disoproxil fumarate (TDF), causes a slightly bigger drop in bone density than other HIV medicines in trials. What that means for fracture risk over many years is not known9. The newer form, tenofovir alafenamide (TAF), had less effect on bone density than TDF in the DISCOVER study10.
If you have had a fracture from a minor fall, or have other reasons to worry about thin bones, mention it to your team. Our article on HIV medicines, tenofovir and your kidneys covers how tenofovir can affect both kidneys and bones.
Liver
- Dolutegravir. Liver problems have been reported with dolutegravir-based treatment. People who also have hepatitis B or C are more at risk, so liver blood tests are part of routine monitoring3.
- Efavirenz. Serious hepatitis, rarely leading to liver failure, has been reported, including in some people with no liver disease before8.
- Stopping treatment when you have hepatitis B. Tenofovir, emtricitabine and lamivudine are also active against hepatitis B. Stopping them suddenly can cause a serious flare of liver inflammation23.
Tell your clinic straight away about yellowing of the skin or eyes, dark urine, pale stools, or pain under the right ribs.
Nerves and body fat: mostly a problem of older medicines
Painful nerve damage in the feet (peripheral neuropathy) and changes in body fat (lipodystrophy) were well-known problems with older HIV medicines such as stavudine, didanosine and zidovudine. Most are no longer used, but some people treated with them years ago still live with these effects1. With modern regimens these problems are uncommon, though tingling and nerve symptoms have been reported occasionally after the medicines came to market3.
Weight and kidneys
These two get their own guides:
- Weight. Weight gain is listed as common for Biktarvy, Dovato and Triumeq. Our guide to HIV medicines and weight gain explains what the research shows and what helps.
- Kidneys. Dolutegravir and bictegravir raise a kidney blood test slightly without harming the kidneys, while tenofovir needs regular checks. See HIV medicines and your kidneys.
Allergic reactions and rashes
- Abacavir. People who carry the HLA-B*5701 gene can have a serious allergic-type reaction, so the gene test is done before abacavir is prescribed, and anyone who reacts must never take it again4. Our Dovato vs Biktarvy vs Triumeq guide explains the test.
- Dolutegravir. Rarely, a reaction with rash, fever and sometimes liver problems. Stop and get medical help immediately if this happens, as a delay can be dangerous3.
- Rilpivirine. Severe skin and allergic reactions have been reported after marketing12.
What to report, and how a switch is decided
Get help urgently for a rash with fever or blistering, swelling of the face or throat, yellow skin or eyes, or thoughts of harming yourself.
Mention at your next visit anything that lingers beyond the first few weeks or affects daily life: poor sleep, low mood, stomach problems, weight change, bone pain.
If a side effect does not settle, there are almost always other options. US guidelines describe three broad approaches1:
- A serious reaction, such as an abacavir allergy or symptomatic liver damage, means stopping all HIV medicines straight away and restarting with a different regimen.
- A problem that is not life-threatening, such as kidney stones on atazanavir or kidney tubule damage on TDF, is usually handled by swapping the medicine responsible, without a break in treatment.
- A long-term issue, such as raised cholesterol, can be handled by switching or by treating the problem directly.
Before any switch, your team looks at your full treatment history, past resistance tests, hepatitis B status and other medicines, then checks your viral load in the months afterwards to make sure the new regimen is working1. Never stop or swap medicines yourself. Our guide to drug resistance and switching explains why.
HIV medicines we supply include Taffic (bictegravir, emtricitabine and tenofovir alafenamide), Inbec (abacavir, dolutegravir and lamivudine) and Efcure 600 mg (efavirenz). Talk to your HIV team before any switch, and all need a prescription.
Frequently asked questions
Do HIV medicines have side effects?
Yes, all medicines can, but modern HIV medicines cause far fewer serious problems than older ones. Most side effects are mild, such as headache, nausea or diarrhoea, and appear in the first few weeks. Some, like weight gain or effects on bones and kidneys, are watched over the longer term.
What are the side effects of Biktarvy?
The most common in the US label are diarrhoea, nausea and headache, mostly mild. The European leaflet also lists abnormal dreams, tiredness and weight gain. Less often, depression has been reported, mainly in people with a history of it. Kidney tests are checked because Biktarvy contains tenofovir alafenamide.
What are the side effects of Dovato?
Headache, nausea, diarrhoea, difficulty sleeping, tiredness and anxiety are the most common in the US label, and abnormal dreams and weight gain are listed as common in Europe. Liver tests are part of monitoring, especially for people with hepatitis B or C.
Can HIV medicine cause heart problems?
Some observational studies linked abacavir with heart attacks, though trial data did not confirm it, and some regimens can raise cholesterol. Your team will look at your overall heart risk, including blood pressure, cholesterol, diabetes and smoking, when choosing treatment.
Does dolutegravir cause insomnia?
Difficulty sleeping is listed as a common side effect of dolutegravir-based pills such as Dovato and Triumeq. It often improves, and changing the time you take your tablet may help. Talk to your team if it continues.
Does HIV treatment cause hair loss?
Hair loss has been reported after marketing with dolutegravir- and lamivudine-containing medicines, but how often is not known and other causes are common. If you notice hair thinning, mention it so your team can check for other reasons too.
Do side effects go away?
Many early side effects, such as nausea, headache or the nervous system effects of efavirenz, ease within a few weeks. Ones that do not settle can usually be managed or solved by switching to another regimen.
Sources & references
- US Department of Health and Human Services, Clinicalinfo. Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents: Adverse Effects of Antiretroviral Medications. Updated 25 September 2025.
- US National Library of Medicine, DailyMed. Biktarvy prescribing information.
- US National Library of Medicine, DailyMed. Dovato prescribing information.
- US National Library of Medicine, DailyMed. Triumeq prescribing information.
- European Medicines Agency. Biktarvy: product information and package leaflet.
- European Medicines Agency. Dovato: product information and package leaflet.
- European Medicines Agency. Triumeq: product information and package leaflet.
- US National Library of Medicine, DailyMed. Efavirenz tablets prescribing information.
- US National Library of Medicine, DailyMed. Viread (tenofovir disoproxil fumarate) prescribing information.
- US National Library of Medicine, DailyMed. Descovy prescribing information (including DISCOVER trial results).
- US National Library of Medicine, DailyMed. Prezista (darunavir) prescribing information.
- US National Library of Medicine, DailyMed. Edurant (rilpivirine) prescribing information.
Related reading
- Life expectancy with HIV on treatment
- Biktarvy explained
- Dolutegravir-based treatment: your first 90 days
- Efavirenz medicines and generic Sustiva
- Abacavir medicines and generic Triumeq
- All HIV and PrEP medicines
This content is for informational purposes only and is not medical advice. Side effects differ from person to person, and your HIV team can help you weigh them against the benefits of your treatment. Never stop or change HIV medicine on your own. Used as prescribed by a licensed medical professional.
Babu S. Shetty is a licensed clinical pharmacist with 14 years of experience. He holds a B.Pharm and M.Pharm from Mohan Kumaramangalam Medical College. At OnlineMeds, he reviews medicine and health content to help ensure it is accurate, evidence-based, and easy to understand.