Cotrimoxazole Prophylaxis in HIV positive individuals Group A

Conclusions 1 Strong but still accumulating evidence that CTX is beneficial in WHO stage 2, 3 or 4 or if CD4 <200. reduction of morbidity and mortality (mortality: except for stage 2) slows HIV disease progression (Uganda) Useful also in areas with high CTX resistance CTX resistance in the lab may not exclude efficacy of CTX as a prophylactic agent

Conclusions 2 Compliance rates 90% Safe 2% side effects Cheap drug Easy to administer

Priority research questions ? CTX in the context of ART When do you stop CTX in patients who start ART. Until CD4 >200 x 3 months? Is there an added benefit of CTX in patients who have access to CTX and ART at the same time? Are there criteria other than CD4s that could be used to decide when to stop CTX (with and without ART) Clinical criteria? Arbitrary time period? Efficacy in patients who are not yet eligible for ART ? Stage 1 and 2 (Cut off for starting CTX set at 500 cells\ul. Too early? Too early: Implies too many patients on CTX: Major implications on workload, resistance development and side effects? Children: Efficacy and side effects

Priority research questions (2) ? Tuberculosis. In HIV positive TB patients, when is the optimal time to start cotrimoxazole (with and without ART)

Priority research questions (3)? Efficacy Regional (Asia). Need for observational data on CTX efficacy in Asia How long will CTX be effective (with and without ART) Increasing resistance? Decreasing adherence?

Priority research questions (4)? Implementation. Best delivery sites for CTX (TB, VCT, ART, PMTCT clinics? (CTX routine use in developing countries, particularly sub-Saharan Africa has been minimal) Long term haematological side effects (with and without ART)

What to do in the meantime ? Follow WHO guidelines HIV positive TB patients Advanced HIV disease Concern on if CD4 500 cells\ul is not too early to start CTX?