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Cotrimoxazole Prophylaxis in HIV positive individuals
Group A
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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
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Conclusions 2
• Compliance rates 90%• Safe 2% side effects• Cheap drug • Easy to administer
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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
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Priority research questions (2) ?
Tuberculosis.
• In HIV positive TB patients, when is the optimal time to start cotrimoxazole (with and without ART)
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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?
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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)
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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?