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PATTERNS OF EFAVIRENZ USE AS FIRST-LINE THERAPY IN THE UNITED STATES: 1999–2015
Angela Bengtson1, Brian W. Pence1, Ellen F. Eaton2, Jessie K. Edwards1, Joseph J. Eron1, W. C. Mathews3, Katie Mollan1, Richard D. Moore4, Connall O’Cleirigh5, Michael J. Mugavero2
1Univ of North Carolina at Chapel Hill, Chapel Hill, NC, USA,2Univ of Alabama at Birmingham, Birmingham, AL, USA,3Univ of California San Diego, San Diego, CA, USA,4Johns Hopkins, Baltimore, MD, USA,5Massachusetts General Hosp, Boston, MA, USA
Between 1999 and 2014 efavirenz was recommended as first-line therapy for HIV-infected adults in the US, and continues to be recommended globally by the WHO. However, efavirenz has been linked to suicidal behavior and may not be appropriate for patients with mental illness.
We examined the patterns of initiating efavirenz-containing first line combination antiretroviral therapy (cART) overall and by mental illness status using data from CNICS, a cohort of 31,000 HIV-infected adults in care at 8 sites in the US. Participants were included if they initiated cART between 1999 and 2015 and were followed from cART initiation until initial cART regimen or cART discontinuation, death, loss to care (>12 months with no HIV appointment), or administrative censoring (Oct 2014-Sept 2015, depending on site), whichever date came first. We used multivariable log binomial models to examine factors associated with initiating and discontinuing efavirenz-containing cART.
We included 9,775 new cART users. Of those, 4,239 (43%) initiated efavirenz-containing cART; and 772 of those participants (18%) discontinued efavirenz. At cART initiation, 2,492 (25%) of participants had a history of a mental illness associated with suicidal behavior, including depression, psychosis, post-traumatic stress disorder, or obsessive compulsive disorder. Efavirenz initiation peaked in 2007 and declined rapidly thereafter (Figure). Over time, persons with a history of a mental illness were modestly less likely to initiate efavirenz-containing cART, compared to those with no history of mental illness. In a multivariable analysis adjusted for site and year of cART initiation, factors associated with initiating efavirenz-containing cART were: prior mono or dual therapy use (prevalence ratio (PR) 0.74, 95% CI 0.66, 0.83), being female (PR 0.80, 95% CI 0.74, 0.86), intravenous drug use (PR 0.83, 95% CI 0.77, 0.90), history of mental illness (PR 0.79, 95% CI 0.75, 0.84) and CD4 cell count >350 (PR 0.91, 95% CI 0.86, 0.95). History of mental illness (PR 1.18, 95% CI 1.02, 1.37) and CD4 cell count >350 (PR 0.86, 95% CI 0.73, 0.98) were associated with discontinuing efavirenz.
Until recently, efavirenz was widely used as first line therapy for HIV-infected adults in the US, including among individuals with a history of mental illness. Given the widespread use of efavirenz globally, greater clarity about the implications of efavirenz use among persons with mental illness is needed.