title: Reducing mortality with cotrimoxazole preventive therapy at initiation of antiretroviral therapy in South Africa.
abstract: OBJECTIVE
  To assess the effectiveness of cotrimoxazole preventive therapy (CPT) among individuals with CD4 cell count above 200 cells/microl and varying WHO clinical stages in reducing mortality during combination antiretroviral therapy (cART).
  
  
  METHODS
  A cohort study.
  
  
  METHODS
  Using proportional hazards modeling, we compared mortality during the first 12 months after cART initiation among patients receiving CPT with patients not receiving CPT. We adjusted for clinic level confounding throughout.
  
  
  RESULTS
  We included 14 097 patients starting cART between January 2003 and January 2008, 62% of whom were men, the median CD4 cell count was 132 cells/microl, and 1289 died (11%). The baseline median CD4 cell count was lower (118 vs. 153 cells/microl) among the 7508 patients who received CPT compared with the 6589 patients who did not. In adjusted multivariate modeling, stratifying for baseline CD4 cell count and WHO stage, CPT reduced mortality overall (hazard ratio 0.64, P < 0.001) and for all individuals with CD4 cell count below 200 cells/microl or WHO clinical stage 3 or 4 conditions but did not reduce mortality for patients with both CD4 cell count above 200 cells/microl and WHO clinical stage 1 or 2.
  
  
  CONCLUSIONS
  We demonstrated a 36% reduction in mortality extending to patients associated with CPT when used with cART that extended to patients with CD4 cell count above 350 cells/microl in a setting with minimal malaria and high rates of cotrimoxazole-resistant bacteria. This provides important additional data toward efforts to increase CPT provision among all cART initiators in resource limited settings.
authors.affiliation: Aurum Institute, Johannesburg, South Africa. choffmann@jhmi.edu
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Hoffmann
authors.forename: Katherine L
authors.initials: KL
authors.lastname: Fielding
authors.forename: Salome
authors.initials: S
authors.lastname: Charalambous
authors.forename: Craig
authors.initials: C
authors.lastname: Innes
authors.forename: Richard E
authors.initials: RE
authors.lastname: Chaisson
authors.forename: Alison D
authors.initials: AD
authors.lastname: Grant
authors.forename: Gavin J
authors.initials: GJ
authors.lastname: Churchyard
mesh_terms: D017088:AIDS-Related Opportunistic Infections / Q000401:mortality / Q000517:prevention & control*; D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use; D000890:Anti-Infective Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D019072:Antibiotic Prophylaxis / Q000379:methods*; D018791:CD4 Lymphocyte Count; D004334:Drug Administration Schedule; D004812:Epidemiologic Methods; D005260:Female; D015658:HIV Infections / Q000188:drug therapy / Q000276:immunology / Q000401:mortality; D015497:HIV-1; D006801:Humans; D008297:Male; D008875:Middle Aged; D013019:South Africa / Q000453:epidemiology; D016896:Treatment Outcome; D015662:Trimethoprim, Sulfamethoxazole Drug Combination / Q000008:administration & dosage / Q000627:therapeutic use*
chemical_list: D019380:Anti-HIV Agents; D000890:Anti-Infective Agents; D015662:Trimethoprim, Sulfamethoxazole Drug Combination