A description of HIV prevalence and plasma efavirenz concentrations amongst suicide attempters at Tshepong Hospital in South Africa

Abstract

Background: Efavirenz(EFV) is currently used in first-line regimens for the treatment of HIV infection in most low-to-middle income countries (LMIC). Suicidality, an increasing problem in South Africa may be associated with HIV as well as EFV. The study describes the HIV prevalence amongst non-fatal suicide attempters (NFSA), the proportion of HIVpositive receiving EFV-containing ART regimens and plasma EFV levels in those taking EFV. Methods: In this prospective study, we enrolled NFSA (aged 18-60) admitted to Tshepong Hospital in the North West Province from October 2017 to July 2018. The Columbia Suicide Severity Rating Scale(C-SSRS) screening tool was used to determine the category of suicidal ideation. We described the proportion on EFV-based ART and measured their EFV concentrations. Results: Of the 119 participants enrolled, 81.4% were female and 95.3% were of African ethnicity. Their mean age was 28.45 years (range, 18-60), 45.4% were HIV positive and 75.9% were on ART, virtually all (95%) receiving EFV. Using the C-SSRS, 78 (73.6%) were in Category 1. No association was found between HIV serostatus and C-SSRS categories (p= 0.999). The mean EFV plasma concentration was 4.45 mcg/ml and mean concentrations were 6.74, 3.65, 1.48 mcg/ml in participants who had viral load of <40, 40-1000, >1000 copies/ml respectively. There was also no statistically significant difference in C-SSRS suicidal ideation category compared to plasma efavirenz concentration (p=0.266). Of the 119, 116 (98.3%) participants attempted suicide by overdose, 65 (55%) revealed their reason was related to personal issues followed by 4 relationship issues 55 (46.2%). 29 (24.4%), 20 (16.8%) and 15 (12.6%) participants reported a history of emotional, physical and sexual abuse respectively. Conclusions: There was a disproportionate number of HIV-seropositive patients amongst non-fatal suicide attempters (NFSA) and most were women. Overdose was the leading mechanism of attempt. Interpersonal factors contribute to suicidal behaviour. We found no associations between suicidal ideation category and HIV serostatus or plasma efavirenz concentration. This is reassuring as EFV remains the backbone of ART regimens in most low-to-middle income (LMIC) countries.