{"id":41376,"date":"2021-10-31T07:31:11","date_gmt":"2021-10-31T07:31:11","guid":{"rendered":"https:\/\/i-base.info\/htb\/?p=41376"},"modified":"2021-11-01T12:10:55","modified_gmt":"2021-11-01T12:10:55","slug":"continued-cotrimoxazole-prophylaxis-at-higher-cd4-counts-in-some-settings","status":"publish","type":"post","link":"https:\/\/i-base.info\/htb\/41376","title":{"rendered":"Benefits reported for continued use of cotrimoxazole prophylaxis at high CD4 counts in Malawi"},"content":{"rendered":"
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Simon Collins, HIV i-Base<\/strong><\/p>\n<\/div>\n

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Although cotrimoxazole prophylaxis is discontinued in high-income countries following CD4 recovery on ART to >200 cells\/mm3<\/sup>, guidelines in many low-income countries recommend continued use even at much higher CD4 counts.<\/strong><\/p>\n<\/div>\n

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Researchers who ran a randomised controlled study in Malawi support this continued use, even though the primary endpoint results were not significant.<\/p>\n<\/div>\n

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The study randomised almost 1500 participants with CD4 counts >250 cells\/mm3<\/sup> to either continue or discontinue daily cotrimoxazole, or switch to daily hydroxychloroquine. Mean CD4 count was actually much higher (568 cells\/mm3<\/sup>, SD+\/\u2013 236).<\/p>\n<\/div>\n

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Neither active arm produced significant benefits based on preventing death or WHO stage 3-4 events (approximate 20% reductions were p=0.20 and p=0.14, respectively). The was linked to the lower event rate than predicted (3.9 vs per 100 patient years of follow-up), reducing the power of the study.<\/p>\n<\/div>\n

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However, when stage 2 secondary endpoints were included<\/span>, the preventive effect increased to 31% (95%CI: 3 to 51%;\u00a0p=0.032) and 32% (95%CI: 4 to 51%;\u00a0p=0.026), for cotrimoxazole and <\/span>hydroxychloroquine respectively. Both drugs significantly reduced the risk of malaria (p<0.001).<\/span><\/p>\n<\/div>\n

Although co-trimoxazole prophylaxis can cause hematologic toxicity, including neutropenia, which was higher in this arm, it didn’t cause higher rates of bacterial infections.<\/span><\/p>\n<\/div>\n

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However the low event rate also means that the number needed to treat (NNT) to prevent and even also becomes much higher, and these data were not presented.<\/span><\/p>\n<\/div>\n<\/div>\n

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These results were first published online in March 2021.<\/span><\/p>\n

comment<\/h3>\n<\/div>\n
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The benefits in this study are likely relevant in high malaria settings and where rates of\u00a0bacterial pneumonia much greater.<\/strong><\/p>\n

Although the confidence intervals are still wide, cotrimoxazole is so safe that this makes sense, especially if vaccination is not available.<\/strong><\/p>\n

Reference<\/span><\/p>\n<\/div>\n

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Laurens MB et al. Revisiting co-trimoxazole prophylaxis for African adults in the era of antiretroviral therapy: a randomized controlled clinical trial. Clinical Infectious Diseases, 73 (6): 1058\u20131065. doi: 10.1093\/cid\/ciab252. (15 September 2021).
\n<\/span>https:\/\/academic.oup.com\/cid\/article-abstract\/73\/6\/1058\/6179299<\/a><\/p>\n

This report was first published on 7 October 2021.<\/em><\/p>\n<\/div>\n","protected":false},"excerpt":{"rendered":"

Simon Collins, HIV i-Base Although cotrimoxazole prophylaxis is discontinued in high-income countries following CD4 recovery on ART to >200 cells\/mm3, guidelines in many low-income countries recommend continued use even at much higher CD4 counts. Researchers who ran a randomised controlled …<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[31],"tags":[],"class_list":["post-41376","post","type-post","status-publish","format-standard","hentry","category-opportunistic-infections-coinfections-and-complications"],"_links":{"self":[{"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/posts\/41376","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/comments?post=41376"}],"version-history":[{"count":0,"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/posts\/41376\/revisions"}],"wp:attachment":[{"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/media?parent=41376"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/categories?post=41376"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/tags?post=41376"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}