Most commonly used HIV drug worldwide not associated with increased risk for suicide in Uganda

A multinational collaboration of researchers found that efavirenz, the key component of the most commonly used HIV cocktail in the world, was not associated with increased risk for depression or suicide in patients living with HIV in Uganda. These findings conflict with previous reports from the United States and Europe linking efavirenz with adverse psychiatric side effects. The study is published in Annals of Internal Medicine.

People living with HIV require lifelong treatment with an effective, safe, and affordable drug cocktail. Because of its side-effects profile, efavirenz is no longer recommended as upfront therapy in the global north. However, due to its low cost and combination with other medicines into a single, once-daily pill, efavirenz is commonly used in Africa, where more than 25 million people are living with HIV.

Researchers sought to determine whether efavirenz caused serious psychiatric side effects in African populations. In a prospective cohort study of 694 adults with HIV in rural Uganda initiating HIV treatment, participants received either efavirenz or nevirapine, a similar HIV medicine that has not been associated with psychiatric symptoms. Subjects were followed for two years with quarterly depression screens, including questions about suicidality.

The authors found no increased risk of depression or suicidal ideation among those receiving efavirenz-based therapy versus nevirapine-based therapy (adjusted odds ratio for depression was 0.62; 95% CI, [0.40-0.96] and for suicidal ideation was 0.61, 95% CI [0.30, 1.25]) comparing those receiving efavirenz to those receiving nevirapine. These relationships were consistent across a broad range of sub-categories of subjects, including those of young and old age, those with and without a history of depression, and those of varying degrees of HIV disease control.

According to the authors, these results contribute guidance around the safety of efavirenz in sub-Saharan Africa. Although additional data are needed comparing efavirenz to newer regimens, these preliminary data on the safety of efavirenz offer some degree of reassurance for its continued use among people receiving treatment for HIV in sub-Saharan Africa.