Initiating co-trimoxazole prophylaxis in HIV-infected patients in Africa: an evaluation of the provisional WHO/UNAIDS recommendations.
OBJECTIVE
To evaluate the proposed WHO/UNAIDS criteria for initiating co-trimoxazole prophylaxis in adult HIV-infected patients in Africa [WHO clinical stages 2--4 or CD4 count < 500 x 10(6) /l or total lymphocyte count (TLC) equivalent].


METHODS
Observational cohort study of 5-year follow-up.


METHODS
Adult HIV clinics, University of Cape Town, South Africa.


METHODS
Effect of prophylactic low dose co-trimoxazole (480 mg per day or 960 mg three times per week) on survival and morbidity was assessed in patients stratified by WHO clinical stage, CD4 T-lymphocyte count or TLC. Patients receiving antiretroviral therapy were excluded.


RESULTS
Co-trimoxazole reduced mortality [adjusted hazard ratio (AHR), 0.56; 95% confidence interval (CI), 0.33--0.85; P > 0.001] and the incidence of severe HIV-related illnesses (AHR, 0.52; 95% CI, 0.38--0.68; P < 0.001) in patients with evidence of advanced immune suppression on clinical (WHO stages 3 and 4) or laboratory assessment (TLC < 1250 x 10(6)/l or CD4 count < 200 x 10(6)/l). No significant evidence of efficacy was found in patients with WHO stage 2 or CD4 count 200--500 x 10(6)/l/TLC 1250--2000 x 10(6)/l. If we had applied the WHO/UNAIDS recommendations 88.3% of our patients would have received co-trimoxazole prophylaxis at their initial clinic visit.


CONCLUSIONS
Co-trimoxazole in HIV-infected adults from an area in which Pneumocystis carinii pneumonia is uncommon demonstrated a survival benefit consistent with previous randomized trials. Further studies are needed to assess the optimal time of commencement of prophylaxis, as widespread co-trimoxazole use will lead to increasing antimicrobial resistance to other major pathogens in Africa.
Badri
M
M
Infectious Diseases Clinical Research Unit, Lung Institute, Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa.
Ehrlich
R
R
Wood
R
R
Maartens
G
G
D017088:AIDS-Related Opportunistic Infections / Q000517:prevention & control*; D000328:Adult; D000890:Anti-Infective Agents / Q000627:therapeutic use*; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006287:Health Planning Guidelines; D006801:Humans; D008297:Male; D011020:Pneumonia, Pneumocystis / Q000517:prevention & control*; D013019:South Africa; D015662:Trimethoprim, Sulfamethoxazole Drug Combination / Q000627:therapeutic use*; D014944:World Health Organization
D000890:Anti-Infective Agents; D015662:Trimethoprim, Sulfamethoxazole Drug Combination