First ART – recommended drug combinations

This information is based on UK guidelines (2023 update).

This will be updated if the guidelines change.

Integrase inhibitor based ART

All guidelines now recommend first-time ART that uses an integrase inhibitor (INSTI).

This is recommended in the UK, US, Europe, and by the World Health Organisation.

• This choice of INSTI is either dolutegravir or bictegravir (in Biktarvy).
• The combination usually also needs to include two nukes. Options for the two nukes.
• Dolutegravir can sometimes be used in a two-drug ART with one nuke (lamivudine, 3TC). The brandname for this option is Dovato.

These two integrase inhibitors have less risk of resistance and generally have fewer side effects than earlier INSTIs.

Alternatives

NNRTI- or PI-based ART is still an alternative if an INSTI can’t be used.

In these cases, guidelines recommend darunavir as the PI and doravirine as the NNRTI.

• Darunavir needs to be taken with food and a booster drug.
• Doravirine can be taken with or without food.
• The INSTI raltegravir can also be used if doultegravir or bictegravir are difficult to tolerate.

Booster drugs

Some combinations include a booster drug (making four drugs overall).

Boosting involves slowing down how your liver processes a drug. This makes the boosted drug stay in your body at higher levels for longer.

• The two drugs used as boosters are ritonavir and cobicistat
• They can be given as separate pills or, for some treatments, combined with one or more other drugs in a single pill.

Viral load after starting ART

In the UK, viral load should be checked after the first month on ART.

Whatever combination you start with, viral load should become undetectable within 1 to 3 months.

Sometimes this might take longer if viral load started off very high – for example over 1 million copies/mL. This report explains examples of viral load sometimes taking longer to become undetectable.

Last updated: 1 September 2024.