Efavirenz Raises Risk of Suicidality

A new analysis of HIV study data confirms a correlation between the antiretroviral drug efavirenz (EFV) and suicidality, showing that patients with a previous history of mental health issues face the highest risk if prescribed the drug.

The new research was designed to analyze incidences of suicidality and self-harm among patients on EFV in 2 groups: those put on antiretroviral therapy (ART) immediately upon diagnosis, and patients whose ART was deferred until certain criteria were met by the patient.

An international team of researchers examined data from the START (Strategic Timing of Antiretroviral Therapy) Study, which included a total of 4,684 patients with HIV. Three-quarters of those patients were prescribed EFV, which was widely recommended at the time patients were being recruited into the study, from 2009 to 2013, according to corresponding author Alejandro Arenas-Pinto, MBBS, MSc, PhD, of University College London.

The data showed that patients who were prescribed EFV had a higher likelihood of suicidal behaviors than those on other ARTs. Dr Arenas-Pinto said those data support recent international guidelines.

“At present, a number of treatment alternatives are available, even in resource-limited countries, to the point that the most recent version of the [World Health Organization] guidelines do not recommend EFV for treatment of HIV disease in patients starting treatment for the first time, regardless of their mental health status,” he told Contagion^®.

As to the difference between immediate and deferred ART initiation, the data showed patients on EFV in the immediate start group had a higher rate of suicidal behaviors than those on deferred treatment. However, Dr Arenas-Pinto noted that patients with an immediate start were highly likely to be given EFV and to be on EFV throughout the study period, whereas patients in the deferred group were on EFV for a shorter amount of time, if at all.

“So, for most of the study period, we were comparing participants on treatment in the immediate ART group against participants not on treatment in the deferred treatment group,” he explained.

Dr Arenas-Pinto noted that the increase in suicidality in immediate versus deferred treatment patients was only present among patients whose treatment regimens included EFV. Therefore, the issue seems to be EFV, rather than whether or not treatment was started immediately.

He added that the overall results of the START study clearly favored immediate initiation of ART.

“The START trial demonstrated a significant, 57% reduction in the risk of developing serious health complications, including severe infections such as TB and different types of cancer, with immediate initiation of antiretroviral therapy as compared to delaying it,” Dr Arenas-Pinto said, noting that immediate ART also decreases the likelihood of sexual transmission of the virus.

In all cases, he noted that patients with a history of mental health problems faced the highest risk of suicidality. In the study, 5.8% of patients had a previous psychiatric diagnosis.

“In particular, EFV should be avoided in patients with a pre-existing mental health problem,” he said. “However, if EFV use is considered, we would recommend that patients be initially screened for depression or other major mental health conditions and, if started on EFV, they should be closely monitored, and their mood assessed regularly by appropriately trained staff.”