title: Effect of cotrimoxazole prophylaxis on malaria occurrence in HIV-infected patients on antiretroviral therapy in sub-Saharan Africa.
abstract: OBJECTIVE
  To systematically review the evidence on the effect of cotrimoxazole (CTX) on malaria in HIV-positive individuals on antiretroviral therapy (ART).
  
  
  METHODS
  Web of Science, PubMed and MEDLINE, EMBASE, Global Health and Cochrane Library databases were searched using terms for malaria, HIV and CTX. Studies meeting the inclusion criteria were reviewed and assessed for bias and confounding.
  
  
  RESULTS
  Six studies (in Uganda, Kenya, Malawi, Zambia and Zimbabwe) had relevant data on the effect of CTX on malaria in patients on ART: four were observational cohort studies (OCS) and two were randomised controlled trials (RCTs); two were in children and one in women only. Samples sizes ranged from 265 to 2200 patients. Four studies compared patients on ART and CTX with patients on ART alone; 2 (RCTs) found a significant increase in smear-positive malaria on ART alone: (IRR 32.5 CI = 8.6-275.0 and HR 2.2 CI = 1.5-3.3) and 2 (OCS) reported fewer parasitaemia episodes on CTX and ART (OR 0.85 CI = 0.65-1.11 and 3.6% vs. 2.4% of samples P = 0.14). One OCS found a 76% (95% CI = 63-84%) vs. 83% (95% CI = 74-89%) reduction in malaria incidence in children on CTX and ART vs. on CTX only, when both were compared with HIV-negative children. The other reported a 64% reduction in malaria incidence after adding ART to CTX (RR = 0.36, 95% CI = 0.18-0.74). The 2 RCTs were unblinded. Only one study reported adherence to CTX and ART, and only two controlled for baseline CD4 count.
  
  
  CONCLUSIONS
  Few studies have investigated the effect of CTX on malaria in patients on ART. Their findings suggest that CTX is protective against malaria even among patients on ART.
authors.affiliation: London School of Hygiene and Tropical Medicine, London, UK.|MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda.
authors.forename: R
authors.initials: R
authors.lastname: Kasirye
authors.affiliation: London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: K
authors.initials: K
authors.lastname: Baisley
authors.affiliation: MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda.
authors.forename: P
authors.initials: P
authors.lastname: Munderi
authors.affiliation: London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: H
authors.initials: H
authors.lastname: Grosskurth
keywords: HIV; VIH; antiretroviral therapy; cotrimoxazol; cotrimoxazole; malaria; paludisme; terapia antirretroviral; thérapie antirétrovirale