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Discontinuation of malaria prophylaxis led to increased malaria risk in adults with HIV
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Adults with HIV on antiretroviral therapy with CD4 counts of more than 200 cells/mcL were at increased risk for malaria and diarrhea if they resided in a malaria-endemic area of Africa and discontinued cotrimoxazole, according to recent study results.
In its 2006 recommendations, the WHO states that no randomized trials to inform the decision to stop cotrimoxazole have been performed in resource-limited settings, the researchers wrote. National guidelines in Uganda recommend that all HIV-infected patients take cotrimoxazole regardless of CD4 count.
Researchers from the CDC conducted a randomized controlled trial of cotrimoxazole discontinuation within an existing study of patients in the Home-Based AIDS Care program in eastern Uganda. Patients initiated ART if they had a CD4 count of at least 250 cells/mcL.
During the study's fourth year, patients with CD4 counts of more than 200 cells/mcL were randomly assigned to continue or discontinue cotrimoxazole. At randomization, there were 836 eligible patients who received ART for a mean of 3.7 years: 452 continued with cotrimoxazole and 384 discontinued treatment.
Compared with 0.4% of those who continued cotrimoxazole who had one episode of malaria, 12.2% of those who discontinued cotrimoxazole had one episode of malaria (P<.001). Among those who continued cotrimoxazole, 14% had at least one episode of diarrhea vs. 25% who discontinued treatment (P<.001). Patients who discontinued cotrimoxazole had a RR for malaria of 32.5 (95% CI, 8.6-275) and a RR for diarrhea of 1.8 (95% CI, 1.3-2.4).
The costs of cotrimoxazole are relatively low, especially compared with ART, but with increasing numbers of infected persons and with those infected living much longer in the era after HAART, lifetime prophylaxis with cotrimoxazole may have cost and toxicity implications, the researchers wrote.
References:
- Campbell JD. Clin Infect Dis. 2012;54:1204-1211.
Disclosures:
- The researchers report no relevant financial disclosures.