Journal of acquired immune deficiency syndromes (1999) 2017 07 26() doi 10.1097/QAI.0000000000001510
Evidence about the effect of initiating efavirenz-containing combination antiretroviral therapy (ART) as first-line therapy on suicidal thoughts remains conflicting.
Using data from a cohort of HIV-infected adults enrolled in routine care across 5 sites in the United States, we included participants with a baseline patient-reported outcome measure and detectable viral load who initiated ART between 2011 and 2014. Participants were followed until the earliest of the following: first suicidal thoughts, discontinuation of initial ART regimen, death, loss to care (>12 months with no HIV appointments), or administrative censoring (2014 to 2015). Suicidal thoughts were measured using a Patient Health Questionnaire-9 item. We used weighted marginal structural Cox models to estimate the effect of initiating efavirenz-containing ART, versus efavirenz-free ART, on the hazard of active or passive suicidal thoughts after ART initiation, accounting for confounding by channeling bias.
Overall, 597 participants were followed for a median of 19 months (13,132 total person-months); 147 (25%) initiated efavirenz-containing ART. At ART initiation, 38% of participants reported suicidal thoughts or depressive symptoms. Initiating efavirenz-based ART was associated with a hazard ratio (HR) for suicidal thoughts below the null in the crude analysis (HR 0.88 (95% CI 0.53, 1.45), and above the null in the weighted analysis (HR 1.21, 95% CI 0.66, 2.28). Among those with a prior mental health issue, the weighted HR was 1.76 (95% CI 0.45, 6.86).
After accounting for measured channeling bias, we observed no strong evidence that initiating efavirenz-containing ART increased the hazard of suicidal thoughts.