HIV Medicine Interactions: Biktarvy, Dovato, Antacids, Supplements, Alcohol and Common Prescriptions

HIV medicines work well, but only if the right amount of medicine reaches your blood every day. Some everyday products, from indigestion remedies to iron tablets, can quietly lower that amount. Other medicines can be pushed to higher levels by some HIV treatments. Most of these interactions are easy to manage once you know about them.

This guide covers the ones that come up most often. It is not a full list. Your pharmacist, and the free Liverpool HIV interaction checker, are the places to check anything specific¹.

Why HIV medicines interact

A drug interaction happens when one medicine, supplement or food changes the way another works². With HIV medicines there are four common ways this happens:

• Binding in the gut. Minerals such as aluminium, magnesium, calcium, iron and zinc can stick to integrase inhibitors (bictegravir, dolutegravir and others) and stop them being absorbed.
• Stomach acid. Rilpivirine and atazanavir need stomach acid to be absorbed, so acid-reducing medicines can lower their levels.
• Medicines that speed up breakdown. Some medicines, such as the TB drug rifampicin, some epilepsy medicines and the herbal remedy St John’s wort, make the liver clear HIV medicines faster. Levels fall, and the virus can become resistant.
• Boosters that slow breakdown. Ritonavir and cobicistat are added to some HIV regimens to keep the main drug at a steady level. They also slow the breakdown of many other medicines, which can build up to unsafe levels.

Antacids, calcium, iron, magnesium and multivitamins

This is the interaction people run into most, because these products are sold without a prescription. The rules for the common integrase inhibitor pills are³⁴⁵:

Rilpivirine taken on its own (Edurant) has a different rule: antacids should be taken at least 2 hours before or at least 4 hours after it⁶. Combination pills that contain rilpivirine, such as Odefsey and Juluca, have their own timings, so check the leaflet that comes with yours.

The simplest habit: take your HIV tablet at a fixed time, and if you take supplements, take them with a meal together with your HIV tablet, or well apart from it. If you are pregnant, the Biktarvy rules are slightly different, so ask your pharmacist³.

Stomach acid medicines (PPIs and H2 blockers)

Omeprazole, lansoprazole, pantoprazole and similar medicines (proton pump inhibitors, or PPIs) are very common. With most modern HIV regimens they cause no problem. Dolutegravir, for example, can be taken with omeprazole without any change⁵. Two HIV medicines are the exception:

• Rilpivirine. PPIs must not be taken with it at all, because they can lower rilpivirine levels enough for treatment to fail. H2 blockers such as famotidine can be used with caution, taken at least 12 hours before or at least 4 hours after rilpivirine⁶.
• Atazanavir. PPIs are not recommended in people who have taken HIV treatment before. In people starting treatment for the first time, a low dose (no more than the equivalent of omeprazole 20 mg) may be used, taken about 12 hours before the atazanavir and ritonavir dose⁷.

Metformin

Dolutegravir and bictegravir both raise the level of metformin, a common diabetes medicine. They block the same kidney “pumps” that clear metformin from the body. Both labels ask the prescriber to weigh up the dose of metformin when the two are used together³⁴. In practice your doctor may keep you on a lower metformin dose or check how you are doing more closely. Our metformin guide covers the medicine itself.

TB medicines and some epilepsy medicines

Rifampicin (called rifampin in the US) is one of the main tuberculosis medicines, and HIV and TB often go together. It lowers the levels of many HIV medicines:

• Biktarvy must not be taken with rifampicin³.
• Dovato and Triumeq can be used, but an extra 50 mg dolutegravir tablet is taken about 12 hours after the usual dose. The same applies to the epilepsy medicine carbamazepine⁴.
• Rilpivirine must not be taken with rifampicin, carbamazepine, oxcarbazepine, phenobarbital or phenytoin⁶.
• Darunavir boosted with ritonavir must not be taken with rifampicin⁸.

If you are treated for TB, your HIV and TB teams will plan both treatments together.

Boosted regimens: ritonavir and cobicistat

If your HIV treatment includes ritonavir or cobicistat (for example darunavir with ritonavir, Prezcobix, Symtuza, Evotaz, Genvoya or Stribild), interactions need the most care. The boosters raise the levels of many other medicines. Some examples from the darunavir and ritonavir label⁸:

• Steroids. Several steroids, including fluticasone and budesonide, given by any route (inhalers, nose sprays, injections or tablets), can build up and cause Cushing’s syndrome and adrenal suppression. Alternatives such as beclomethasone, prednisone or prednisolone are preferred.
• Statins. Simvastatin and lovastatin must not be used. Atorvastatin, rosuvastatin and pravastatin can be used at the lowest dose that works, and atorvastatin should not go above 20 mg a day. See our statin comparison.
• Erectile dysfunction medicines. Levels rise, with more risk of low blood pressure, fainting, vision changes and a prolonged erection. The label limits doses to sildenafil no more than 25 mg in 48 hours, vardenafil no more than 2.5 mg in 72 hours, or tadalafil no more than 10 mg in 72 hours. Avanafil is not recommended. Our guide on how to take sildenafil explains normal dosing.
• Sleeping tablets and sedatives. Midazolam taken by mouth and triazolam must not be used.
• Other medicines that must not be combined include alfuzosin (for prostate symptoms), colchicine in people with kidney or liver problems, some heart rhythm medicines, ergot medicines for migraine, and St John’s wort.

Unboosted pills such as Biktarvy and Dovato have far fewer of these interactions, which is one reason they are so widely used.

Alcohol and recreational drugs

Neither the Biktarvy nor the Dovato US label lists alcohol as a direct drug interaction³⁴. For abacavir (in Triumeq), the label notes that alcohol slows the way the body clears abacavir, so more of it stays in the blood⁹.

The bigger concerns are practical. HIV.gov points out that heavy drinking and drug use can harm the immune system and the liver, make side effects more likely, and make it easier to miss doses. Excessive drinking is particularly risky for anyone who also has hepatitis B or C. Some recreational drugs also interact with HIV medicines, and certain HIV medicines can push some recreational drugs to dangerously high levels¹⁰. HIV.gov’s advice is simple: be honest with your doctor and pharmacist about anything you use, so they can check it.

If you drink, the safest habits are to keep to moderate amounts, never skip your HIV dose because you have been drinking, and set a reminder if a night out might throw off your usual time. Our guide on missed doses explains what to do if it happens.

Herbal products and supplements

St John’s wort, a herbal remedy for low mood, is the best-known problem. It is not recommended with Biktarvy, should be avoided with Dovato, and must not be taken with rilpivirine or with boosted darunavir³⁴⁶⁸. For other herbal and “natural” products there is often little research, which is a reason to ask before starting them, not a reason to assume they are safe.

Common medicines that are usually fine

It helps to know what is not a problem too. The Biktarvy label found no meaningful interaction with the combined contraceptive pill (ethinyl estradiol with norgestimate), the antidepressant sertraline, or the hepatitis C medicines sofosbuvir and velpatasvir³. The dolutegravir label lists the contraceptive pill, methadone, omeprazole and prednisone among medicines that can be used without a dose change⁵. Our guide to the combined pill covers contraception more generally.

Painkillers deserve a word. Occasional paracetamol (acetaminophen) or ibuprofen is a common question. For people on tenofovir, especially with kidney risk factors, regular or high-dose anti-inflammatory painkillers need care. Our article on HIV medicines and your kidneys explains why.

Keep one list, and check it

• Keep one up-to-date list of everything you take: prescriptions, over-the-counter products, vitamins, herbal products and recreational drugs.
• Use one pharmacy if you can, so one pharmacist can see everything.
• Tell every prescriber, including dentists and hospital doctors, that you take HIV medicine.
• Check new products on the Liverpool HIV interaction checker¹, which pharmacists and doctors around the world use, and take the result to your pharmacist.

HIV medicines discussed here that we supply include Biktarvy, Doluvir 50 mg (dolutegravir) and Durart-R (darunavir with ritonavir). Always check a new medicine with your pharmacist, and all need a prescription.

Frequently asked questions

Can I drink alcohol on HIV meds?

Alcohol is not listed as a direct interaction for Biktarvy or Dovato. Heavy drinking is the concern: it can harm the liver and immune system and makes missed doses more likely. Alcohol does raise abacavir levels. Talk openly with your team about how much you drink.

Can I take ibuprofen with Biktarvy?

Occasional use is a question for your pharmacist, who knows your kidney results. Biktarvy contains tenofovir alafenamide, and its label notes that people with reduced kidney function who also take anti-inflammatory painkillers are at higher risk of kidney problems.

Can I take magnesium with Dovato?

Yes, with spacing. Take Dovato 2 hours before, or 6 hours after, products containing magnesium or aluminium, such as many antacids and some laxatives and supplements.

Can I take Viagra with HIV medicine?

Often yes, but it depends on the regimen. With boosted regimens (ritonavir or cobicistat), sildenafil is limited to 25 mg in 48 hours, tadalafil to 10 mg in 72 hours, and vardenafil to 2.5 mg in 72 hours. The Biktarvy and Dovato labels do not list ED medicines as an interaction. Check with your pharmacist either way.

Can I take the contraceptive pill with Biktarvy?

The Biktarvy label found no meaningful interaction with a combined pill containing ethinyl estradiol and norgestimate. Other HIV regimens, especially boosted ones with ritonavir or cobicistat, can be different, so check with your pharmacist.

Can I take omeprazole with HIV medicine?

With dolutegravir, yes. With Biktarvy it is not listed as an interaction. With rilpivirine it must not be used, and with atazanavir it is either not recommended or limited to a low dose taken 12 hours apart.

Do antidepressants interact with Biktarvy?

The label found no meaningful interaction with sertraline. Other antidepressants, and St John’s wort in particular, should be checked with your pharmacist.

Sources & references

1. University of Liverpool. HIV Drug Interactions checker.
2. National Institutes of Health (HIVinfo). What is a Drug Interaction?
3. US National Library of Medicine, DailyMed. Biktarvy prescribing information.
4. US National Library of Medicine, DailyMed. Dovato prescribing information.
5. US National Library of Medicine, DailyMed. Tivicay (dolutegravir) prescribing information.
6. US National Library of Medicine, DailyMed. Edurant (rilpivirine) prescribing information.
7. US National Library of Medicine, DailyMed. Reyataz (atazanavir) prescribing information.
8. US National Library of Medicine, DailyMed. Prezista (darunavir) prescribing information.
9. US National Library of Medicine, DailyMed. Triumeq prescribing information.
10. HIV.gov. Alcohol and Drug Use.

Related reading

• Travelling with HIV medication
• Dovato vs Biktarvy vs Triumeq
• HIV medicines and your kidneys
• NSAIDs explained: ibuprofen, naproxen and diclofenac
• Darunavir medicines, ritonavir medicines and generic Prezista
• Dolutegravir medicines and all HIV and PrEP medicines

This content is for informational purposes only and is not medical advice. It covers common interactions only. Always check new medicines, supplements and other products with your pharmacist or HIV team, and never stop or change HIV medicine on your own. Used as prescribed by a licensed medical professional.