title: Longitudinal effect of CD4 by cotrimoxazole use on malaria incidence among HIV-infected Ugandan adults on antiretroviral therapy: a randomized controlled study.
abstract: The effect of CD4 count on malaria incidence in HIV infected adults on antiretroviral therapy (ART) was assessed in the context of a randomized controlled trial on the effect of stopping cotrimoxazole (CTX).
  
  
  
  This study presents a sub-analysis of the COSTOP trial (ISRCTN44723643) which was carried out among HIV-infected Ugandan adults stable on ART with CD4 counts ≥250 cells/µl. Participants were randomized (1:1) to continue CTX or stop CTX and receive matching placebo, and were followed up for a minimum of 1 year (median 2.5 years). CD4 counts were measured at baseline, 3 months and then every 6 months. Clinical malaria was defined as fever and a positive blood slide. First, the relationship between current CD4 count during follow-up and malaria among participants on placebo was examined; using random effects Poisson regression to account for repeated episodes. Second, the effect of CD4 count at enrolment, CD4 count at ART initiation, and CD4 count during follow-up on malaria, was assessed within each trial arm; to examine whether the effect of CD4 count differed by CTX use.
  
  
  
  2180 participants were enrolled into the COSTOP trial. The incidence of clinical malaria was approximately four episodes/100 person years in the CTX arm and 14 episodes/100 person years in the placebo arm. There was no evidence of an association of current CD4 and clinical malaria incidence (P = 0.56), or parasitaemia levels (P = 0.24), in the placebo arm. Malaria incidence did not differ by CD4 count at ART initiation, enrolment or during follow up, irrespective of CTX use. When compared with participants in the lowest CD4 stratum, rate ratios within each trial arm were all close to 1, and P values were all above P = 0.30.
  
  
  
  The immune status of HIV infected participants who are stable on ART as measured by CD4 count was not associated with malaria incidence and did not modify the effect of stopping CTX on malaria. The decision of whether to stop or continue CTX prophylaxis for malaria in HIV infected individuals who are stable on ART should not be based on CD4 counts alone. COSTOP trial registration number ISRCTN44723643.
authors.affiliation: MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda. ronniekasirye@yahoo.com.|London School of Hygiene and Tropical Medicine, London, UK. ronniekasirye@yahoo.com.
authors.forename: Ronnie
authors.identifier: 0000-0002-5200-464X
authors.initials: R
authors.lastname: Kasirye
authors.affiliation: MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda.|London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Heiner
authors.initials: H
authors.lastname: Grosskurth
authors.affiliation: MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda.
authors.forename: Paula
authors.initials: P
authors.lastname: Munderi
authors.affiliation: MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda.|School of Public Health, University of Witwatersrand, Johannesburg, South Africa.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Levin
authors.affiliation: MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda.
authors.forename: Zacchaeus
authors.initials: Z
authors.lastname: Anywaine
authors.affiliation: MRC Clinical Trials Unit at University College London, London, UK.
authors.forename: Andrew
authors.initials: A
authors.lastname: Nunn
authors.affiliation: MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda.
authors.forename: Anatoli
authors.initials: A
authors.lastname: Kamali
authors.affiliation: London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Kathy
authors.initials: K
authors.lastname: Baisley
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D044966:Anti-Retroviral Agents / Q000008:administration & dosage; D000962:Antimalarials / Q000008:administration & dosage*; D023241:Antiretroviral Therapy, Highly Active; D018791:CD4 Lymphocyte Count; D015496:CD4-Positive T-Lymphocytes / Q000276:immunology*; D018890:Chemoprevention / Q000379:methods; D004311:Double-Blind Method; D005260:Female; D005500:Follow-Up Studies; D015658:HIV Infections / Q000150:complications* / Q000276:immunology; D006801:Humans; D015994:Incidence; D008288:Malaria / Q000453:epidemiology* / Q000517:prevention & control*; D008297:Male; D008875:Middle Aged; D010919:Placebos / Q000008:administration & dosage; D015662:Trimethoprim, Sulfamethoxazole Drug Combination / Q000008:administration & dosage*; D014454:Uganda / Q000453:epidemiology; D055815:Young Adult
chemical_list: D044966:Anti-Retroviral Agents; D000962:Antimalarials; D010919:Placebos; D015662:Trimethoprim, Sulfamethoxazole Drug Combination
keywords: Antiretroviral therapy; CD4; Cotrimoxazole; HIV; Malaria