Adults with HIV on antiretroviral therapy with CD4
counts of more than 200 cells/mcL were at increased risk for malaria and
diarrhea if they resided in a malaria-endemic area of Africa and discontinued
cotrimoxazole, according to recent study results.
In its 2006 recommendations, the WHO states that
no randomized trials to inform the decision to stop cotrimoxazole have been
performed in resource-limited settings, the researchers wrote.
National guidelines in Uganda recommend that all HIV-infected patients
take cotrimoxazole regardless of CD4 count.
Researchers from the CDC conducted a randomized
controlled trial of cotrimoxazole discontinuation within an existing study of
patients in the Home-Based AIDS Care program in eastern Uganda. Patients
initiated ART if they had a CD4 count of at least 250 cells/mcL.
During the study's fourth year, patients with CD4
counts of more than 200 cells/mcL were randomly assigned to continue or
discontinue cotrimoxazole. At randomization, there were 836 eligible patients
who received ART for a mean of 3.7 years: 452 continued with cotrimoxazole and
384 discontinued treatment.
Compared with 0.4% of those who continued cotrimoxazole
who had one episode of malaria, 12.2% of those who discontinued cotrimoxazole
had one episode of malaria (P<.001). Among those who continued
cotrimoxazole, 14% had at least one episode of diarrhea vs. 25% who
discontinued treatment (P<.001). Patients who discontinued
cotrimoxazole had a RR for malaria of 32.5 (95% CI, 8.6-275) and a RR for
diarrhea of 1.8 (95% CI, 1.3-2.4).
The costs of cotrimoxazole are relatively low,
especially compared with ART, but with increasing numbers of infected persons
and with those infected living much longer in the era after HAART, lifetime
prophylaxis with cotrimoxazole may have cost and toxicity implications,
the researchers wrote.
- Campbell JD. Clin Infect Dis. 2012;54:1204-1211.
- The researchers report no relevant financial disclosures.