What Not to Eat When on ARVs?: A Comprehensive Guide to Food and Drug Interactions

October 7, 2025 •

4 min read

Because HIV affects the immune system, people taking antiretroviral (ARV) medications must be mindful of their diet [1.2.1]. Answering the question 'What not to eat when on ARVs?' is critical, as certain foods and supplements can impact medication effectiveness or increase side effects [1.3.2].

Quick Summary

A detailed overview of foods, supplements, and beverages to avoid or use with caution while on antiretroviral medication. It covers specific interactions and provides safer dietary alternatives for HIV management.

Key Points

Grapefruit: Avoid grapefruit and Seville oranges, as they can dangerously increase levels of certain ARVs like protease inhibitors by inhibiting metabolic enzymes [1.4.1].
St. John's Wort: This herbal supplement is contraindicated as it significantly lowers ARV blood levels, leading to a high risk of treatment failure and drug resistance [1.5.2, 1.5.1].
Food Safety: People with HIV should avoid raw or undercooked foods like meat, eggs, and seafood to prevent serious foodborne illnesses due to a weakened immune system [1.2.1, 1.6.3].
Alcohol: Limit or avoid heavy alcohol consumption as it can strain the liver, worsen ARV side effects, and negatively impact medication adherence [1.7.1, 1.7.2].
Mineral Supplements: Take calcium or iron supplements 2 hours before or 6 hours after integrase inhibitors to prevent reduced drug absorption [1.8.3, 1.8.4].
Garlic Supplements: High-dose garlic supplements should be used with caution as they can reduce the effectiveness of certain protease inhibitors [1.9.3].
Communication is Key: Always inform your healthcare provider about all foods, supplements, and over-the-counter products you consume to prevent harmful interactions.

Understanding ARVs and the Importance of Diet

Antiretroviral therapy (ART) is the use of HIV medicines to treat HIV infection. For people with HIV, a healthy diet helps maintain a healthy weight and supports the immune system [1.6.2]. However, the relationship between food and ARVs goes deeper than general nutrition. Some foods, drinks, and supplements can interfere with how the body processes these life-saving medications. These interactions can happen in a few ways: they can affect the absorption of a drug, leading to lower levels in the body, or they can affect the metabolism of a drug, leading to dangerously high levels and increased risk of side effects [1.3.1]. Because of a compromised immune system, people with HIV are also more susceptible to foodborne illnesses, making food safety a paramount concern [1.2.1, 1.6.3].

Foods and Beverages with Known Interactions

Certain items should be approached with caution or avoided entirely to ensure your ARV regimen works as intended.

Grapefruit and Seville Oranges

Grapefruit and certain other citrus fruits like Seville oranges (bitter oranges) and pomelos can inhibit an enzyme called CYP3A4, which is responsible for metabolizing many drugs, including several ARVs [1.4.1]. By blocking this enzyme, these fruits can cause the concentration of certain protease inhibitors (PIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs), and integrase inhibitors (INSTIs) to increase in the bloodstream [1.4.1]. This raises the risk of drug toxicity. It is generally recommended that patients on these types of ARVs avoid or significantly limit grapefruit consumption [1.4.1].

Alcohol

While moderate alcohol consumption is not strictly forbidden, heavy drinking should be avoided. Alcohol can put extra strain on the liver, which is also responsible for processing most ARV medications [1.7.1]. This can exacerbate liver-related side effects of some ARVs [1.7.1, 1.7.2]. Furthermore, alcohol can impair judgment, which may lead to missed medication doses—a critical issue in HIV management where adherence of 95% or higher is often necessary for the treatment to be effective [1.7.1]. It can also worsen side effects like dizziness associated with certain medications, such as efavirenz [1.7.3].

Raw and Undercooked Foods

Due to a weakened immune system, people with HIV have a significantly higher risk of developing serious foodborne illnesses [1.6.3]. Therefore, it is crucial to avoid foods that carry a high risk of bacterial or parasitic contamination. These include:

Raw or undercooked eggs (including in homemade cookie dough or Caesar dressing) [1.2.1, 1.2.2]
Raw or undercooked meat, poultry, and seafood (like sushi, oysters, or steak tartare) [1.2.1, 1.2.2]
Unpasteurized milk, dairy products, and fruit juices [1.2.1, 1.6.3]
Soft cheeses made from unpasteurized milk, such as Brie and Camembert [1.2.4]

Practicing strict food safety—cleaning hands and surfaces, separating raw and cooked foods, cooking to proper temperatures, and chilling food promptly—is essential [1.6.2].

Herbal Supplements: A Major Concern

Many individuals use herbal supplements, but these can have powerful effects and interact with conventional medicines. For those on ARVs, some supplements are strictly contraindicated.

St. John's Wort

The herbal supplement St. John's wort, often used for depression, is a potent inducer of the CYP3A4 enzyme [1.5.3, 1.5.5]. This is the opposite effect of grapefruit. It speeds up the metabolism of many PIs and NNRTIs, causing their levels in the blood to drop significantly [1.5.2, 1.5.3]. These sub-therapeutic drug levels can lead to treatment failure and the development of drug resistance [1.5.2]. For this reason, taking St. John's wort is contraindicated with most ARV regimens [1.5.1].

Garlic Supplements

While garlic in food is generally safe, high-dose garlic supplements have been shown to reduce the blood levels of the protease inhibitor saquinavir by over 50% [1.9.2]. The interaction is thought to be caused by garlic inducing enzymes and transport proteins that clear the drug from the body [1.9.3]. Due to this risk, using high-dose garlic supplements with caution is advised, especially for patients taking PIs [1.9.3].

Mineral Supplements (Calcium, Iron)

Some ARVs, particularly integrase inhibitors like dolutegravir and bictegravir, can bind to polyvalent cations found in supplements like calcium, iron, and magnesium, as well as in antacids [1.8.1, 1.8.4]. This process, called chelation, prevents the ARV from being properly absorbed into the bloodstream, reducing its effectiveness [1.8.1]. To avoid this, it is recommended to take these ARVs at least 2 hours before or 6 hours after taking such supplements or antacids [1.8.3, 1.8.4]. However, if taken with a meal, the interaction with calcium or iron may be less significant [1.8.2].

Comparison Table: ARV Classes and Common Interactions


ARV Class/Drug	Interacting Food/Supplement	Potential Effect	Recommendation
Protease Inhibitors (PIs) (e.g., Atazanavir, Darunavir)	Grapefruit, Seville Oranges [1.4.1]	Increases drug levels, risk of toxicity.	Avoid consumption [1.4.1].
	St. John's Wort [1.5.2]	Decreases drug levels, risk of treatment failure.	Contraindicated; Do not use [1.5.1].
	High-Dose Garlic Supplements [1.9.3]	Decreases drug levels.	Use with caution [1.9.3].
NNRTIs (e.g., Efavirenz, Rilpivirine)	St. John's Wort [1.5.2]	Significantly decreases drug levels.	Contraindicated; Do not use [1.5.1].
	Antacids (with Rilpivirine) [1.3.4]	Decreases drug absorption.	Separate administration times.
Integrase Inhibitors (INSTIs) (e.g., Dolutegravir, Bictegravir)	Supplements with Calcium, Iron, Magnesium; Antacids [1.8.1, 1.8.4]	Decreases drug absorption due to chelation.	Take ARV 2 hours before or 6 hours after supplement [1.8.3].

Conclusion

Managing HIV with antiretroviral therapy is a collaborative effort between a patient and their healthcare provider. While ARVs are highly effective, their success depends on consistent adherence and avoiding substances that can interfere with them. Foods like grapefruit, supplements like St. John's wort and high-dose garlic, and minerals like calcium and iron can all have clinically significant interactions. Additionally, practicing rigorous food safety by avoiding raw or undercooked products is vital for preventing opportunistic infections. Always communicate openly with your doctor or pharmacist about everything you consume, including over-the-counter medications, herbal products, and dietary supplements, to ensure the safety and effectiveness of your HIV treatment.

For more detailed information on food safety, visit HIV.gov. [1.6.3]

Frequently Asked Questions

Yes, consuming garlic in normal culinary amounts is generally considered safe. The concern is primarily with high-dose garlic supplements, which have been shown to reduce the blood levels of some ARV drugs, particularly certain protease inhibitors [1.9.2, 1.9.3].

Moderate alcohol intake (one or two drinks) is unlikely to cause a direct interaction with ARVs, but heavy drinking should be avoided. Alcohol can increase stress on the liver, worsen medication side effects, and interfere with your ability to take your pills on time [1.7.1, 1.7.3].

Regular sweet oranges (like Navel or Valencia) and lemons do not contain the same compounds as grapefruit, pomelos, and Seville (bitter) oranges and do not have the same interaction risk with the CYP3A4 enzyme [1.4.1]. They are generally safe to consume.

St. John's wort speeds up the body's process of breaking down many ARV drugs. This causes the medication levels in your blood to drop to ineffective amounts, which can lead to the virus replicating and developing resistance to your treatment [1.5.2, 1.5.3].

Not necessarily, but you need to be cautious about multivitamins containing minerals like calcium, magnesium, or iron. If you take an integrase inhibitor (like dolutegravir or bictegravir), you must space out your ARV and the multivitamin by several hours to ensure proper absorption [1.8.3, 1.8.4].

Because HIV weakens the immune system, you are more vulnerable to bacteria and parasites found in raw or undercooked foods. Raw fish can carry pathogens that might cause a mild illness in a healthy person but could lead to a severe, prolonged illness for someone who is immunocompromised [1.2.1, 1.6.3].

A single, accidental exposure is unlikely to cause a major problem, but you should inform your healthcare provider or pharmacist. They can advise you on whether any monitoring is needed and reinforce the importance of avoiding the substance in the future.