Most HIV drugs can affect your liver as this is the way that they are filtered by your body. This is why your routine blood tests will include tests to check your liver function. Ritonavir and nevirapine are particularly associated with liver toxicity.

The following factors can increase the risk of liver complications from HIV treatment:

Liver function test (LFT) is carried out with the blood to test for CD4 count and viral load. For those who have hepatitis or previous liver damage it is recommended that TDM be done when taking protease inhibitors or NNRTIs, as a dose reduction may be necessary.

When taking anti-HIV drugs report any side effects to your doctor, especially where you have abdominal pain, nausea and vomiting, yellowing of the skin or the whites of the eyes.

Where liver toxicity is suspected, the drugs will normally be stopped to allow the liver to rest and return to normal. When the liver tests have returned to normal HIV drugs may be restarted; often a different combination of drugs or reduced doses may be necessary to prevent further liver problems.

Thioctic acid and milk thistle (silymarin) can help lower liver enzymes. To cleanse the liver a combination of beet juice, carrot juice, black radish extract and dandelion extract are useful, but can be very powerful, go easy. Chlorophyll and distilled water with lemon juice are also excellent purifiers that may be more mild. Other herbs and food supplements that may be used: dandelion, celandine, glycerrhizin, chickory and astragalus.

Special guidelines on using nevirapine were issued last year by the EMEA (the European regulatory agency) to all doctors and this is why there is a separate section in this guide.

For those people starting on nevirapine, close monitoring in the first two months of therapy is very important, as this is normally when liver problems first start to occur. Liver toxicity can still occur after many months and may build up slowly, so continued routine monitoring is also important after the first two months.

This is particularly important for women as research has shown that women taking nevirapine are more likely to develop liver problems. Nevirapine must be taken as one tablet (200mg) once daily for the first two weeks.

Only if you have none of the symptoms listed below and your liver function tests are within the acceptable levels can you increase your nevirapine dose to one tablet (200mg) twice a day.

Blood samples should be taken every two weeks in the first two months to check liver function, then at the end of the third month, and then every three to four months if they are within normal limits

During this first eight weeks you should contact your doctor straight away if you have any of the following symptoms:

Your need another liver function blood test if you have one of these symptoms.

If the results are not higher than twice the normal limit, and depending on the severity of your symptoms, a decision will be made whether or not to continue with nevirapine. If you continue, you will be very closely monitored to ensure that the symptoms do not progress or your liver function tests get worse.

If at any point your liver function tests get to five times the normal limit or mild symptoms get worse, then your nevirapine must be stopped. Your doctor will recommend whether you need to stop all your treatments or just switch the nevirapine to another drug.

If you stop nevirapine for these reasons, you must not take it again in the future.