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Cotrimoxazole prophylaxis in high HIV prevalence settings

Cotrimoxazole prophylaxis in high HIV prevalence settings. Development of a Policy ? Dr Rony Zachariah WHO TB/HIV Meeting, Montreux June 2003. HIGH MORTALITY - HIV. HIV+, Smear +ve PTB : 20-30% HIV+ Smear –ve and EPTB : 40-50%. OPPORTUNISTIC INFECTIONS.

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Cotrimoxazole prophylaxis in high HIV prevalence settings

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  1. Cotrimoxazole prophylaxis in high HIV prevalence settings Development of a Policy ? Dr Rony Zachariah WHO TB/HIV Meeting, Montreux June 2003

  2. HIGH MORTALITY - HIV • HIV+, Smear +ve PTB : 20-30% • HIV+ Smear –ve and EPTB : 40-50%

  3. OPPORTUNISTIC INFECTIONS • HIV related infections - Morbidity and Mortality • Interventions - to prevent infections might improve survival.

  4. COTRIMOXAZOLE PROPHYLAXIS Useful against:- • Pneumocystis carinii pneumonia • Toxoplasma encephalitis • Isospora belli diarrhoea • Some bacteria and enterobacteria • Nocardiosis • Falciparum malaria

  5. Advantages Cheap Widely available Easy to administer Disadvantages Side effects Drug resistance Lack of efficacy COTRIMOXAZOLE PROPHYLAXIS

  6. Cotrimoxazole in the Western World • Reduces PCP related mortality • Routinely administered to HIV positive individuals (CD4 < 200/mm3)

  7. Cotrimoxazole in Cote d’Ivoire 771 HIV-positive smear+ve TB patients on short course chemotherapy one month later - cotrimoxazole or placebo Cotrimoxazole associated with 46% lower mortality 43% lower hospitalisation rate (Wiktor et al Lancet 1999;353: 1469-1475)

  8. Cotrimoxazole in South Africa • WHO Stage 3 & 4 Lower mortality AHR 0.56 (TB 0.38) Lower morbidity AHR 0.52 (TB 0.23) • WHO stage 2: No benefit (Badri et al AIDS 2001;15: 1143-1148) (Badri et al Lancet 1999;354: 333-334)

  9. Cotrimoxazole in Malawi (1) 1986 TB patients - on anti-TB treatment intervention group : 1061 (VCT/Cotrimoxazole) control group : 925 Cotrimoxazole & VCT uptake ± 90% adherence > 90% side effects < 2% Mortality25% lower mortality (Zachariah et al AIDS 2003;17: 1053-1061)

  10. Cotrimoxazole in Malawi (2) • Number needed to treat analysis: Giving VCT and Cotrimoxazole to 12 TB patients registered under routine conditions will prevent 1 death during anti-TB treatment

  11. Cotrimoxazole in Malawi (3) Why high VCT uptake ? • Integrated and systematic • Rapid HIV testing • Quality of VCT (counsellors/ infrastructure) • Incentives: Cotrimoxazole /social support and home based care. • Zachariah R, Spielmann MP, AD Harries et al. Int J Tuberc Lung Dis6:1046-1050

  12. Cotrimoxazole in Malawi (4) Why high adherence ? • Drug is highly valued by the patient • Limited problems of disclosure associated with daily pill intake at home « CARE » model counselling • Home Based Care • Zachariah R, Spielmann MP, AD Harries et al. • Int J Tuberc Lung Dis 2003, 7:65-71 • Int J Tuberc Lung Dis 2001 5:843-846

  13. Recommendations: TB patients Offer VCT to all TB patients and cotrimoxazole to all those who are HIV + (minimum package of HIV/TB care)

  14. Benefits Reduce death rates Incentive for VCT Integration - TB/HIV Considerations Increased cost Side effects. Feasibility VCT & Cotrimoxazole: TB patients

  15. THE EQUITY ISSUE ?

  16. HIV+ non TB patients with WHO Stage 2, 3, 4 What should the Policy be? • WHO/UNAIDS recommends cotrimoxazole for WHO stage 2-4 • Reasonable for WHO stage 3 and 4 • Unclear for WHO stage 2 Maybe a country specific policy?

  17. Practical considerations • Who pays ? • Who administers after anti-TB treatment ? • Resistance development ? Fansidar - malaria RTI / Diarrhoea • Alternative options ? • Effect of HAART on cotrimoxazole ?

  18. CONCLUSIONS VCT and cotrimoxazole : • Is one of the only offers for reducing mortality in HIV+ individuals in resource poor countries. • Is an opportunity for integrating HIV/TB care. • Is an essential first step towards establishing comprehensive HIV care.

  19. ACKNOWLEDGEMENTS • World Health Organisation • National TB control program – Malawi • Medecins Sans Frontieres

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