4. 8 Liver problems, fatty liver and rash
Liver toxicity
Although most HIV meds are filtered by the liver, it is rare for modern HIV drugs to cause liver problems.
But routine blood tests for everyone on ART monitors liver enzymes (ALT or AST, GGT, albumin etc) to pick up cases when this does occur.
Most liver problems are related more to coinfections with viral hepatitis (hep A, B or C) or to alcohol use, than to ART.
In the past, a low risk of serious liver toxicity was linked to the NNRTIs nevirapine and efavirenz. Nevirapine is now rarely used in most countries and efavirenz is no longer recommended as first-line ART in WHO guidelines. Less than 5% of people using these drugs in research studies needed to change treatment for this reason.
This is still important to know about in countries where these drugs are still used.
Liver toxicity from HIV drugs usually occurs in the first six weeks of treatment, but can also occur later. Hepatitis coinfection increases the risk of liver toxicity and might affect your choice of ART.
The normal range for liver function tests is used to grade liver toxicity. Usually you results needs to be 2–5 times the upper limit for this to be a low level grade 2 side effect.
- The normal range of ALT for men is 10–55 U/L and for women is 7–30 U/L.
- An ALT score between 110–275 for men and 60–150 for women counts as grade 2.
See:
Rash
About 10% people who use nevirapine or efavirenz get a low level rash that is not serious. Rash can also occur with other HIV drugs.
About 1 in 20 people discontinue efavirenz or nevirapine the rash is more serious.
1% people can be at risk of a much more serious rash, especially using nevirapine.
Nevirapine should be dosed at 200 mg once-daily for the first two weeks. If there is no rash at the end of these two weeks then the dose increases to 400 mg a day.
The staggered dose is just as important with fixed dose combinations, but sometimes in practice it is ignored.
The nevirapine dose should never be increased if you still have a rash.
If any rash covers more than 10% of your body or breaks the skin at all, you must see your doctor immediately.
In these rare cases, nevirapine has to be stopped very quickly to reduce the risk of a severe reaction that can be fatal.
This is something you should check and ask your doctor about.
Further reading
Information about liver-related side effects from the i-Base guide to side effects and other complications.
Last updated: 1 January 2023.