Lower early mortality rate among patients receiving antiretroviral treatment at clinics offering cotrimoxazole prophylaxis in Malawi

HIV/AIDS Care and Treatment Branch, Global AIDS Program, Us centers for Disease Control and Prevention (CDC), Atlanta, GA, USA.
JAIDS Journal of Acquired Immune Deficiency Syndromes (Impact Factor: 4.39). 09/2007; 46(1):56-61. DOI: 10.1097/QAI.0b013e3181378ed2
Source: PubMed

ABSTRACT To determine whether Malawi antiretroviral treatment (ART) clinics providing cotrimoxazole (CTX) prophylaxis had lower early mortality rates compared with clinics not providing CTX.
Retrospective cohort study of eleven ART clinics in Malawi that were or were not providing CTX. Medical record abstraction was performed for all patients (N = 1295) initiating ART between July 1 and December 15, 2005. At 5 ART sites, CTX was given to patients dosed at 960 mg daily or 480 mg twice a day (according to national guidelines).
When all defaults (patients lost to follow-up for >90 days) were excluded from the analysis, the 6-month mortality rate was 10.7% in patients receiving ART at CTX clinics compared with 18.0% in those not at CTX clinics (6-month mortality risk reduction = 40.7%; P = 0.0013). Kaplan-Meier survival curves for patients receiving CTX and patients not receiving CTX were significantly different; survival differences were apparent as early as 40 to 45 days after initiation of ART.
Patients receiving ART in Malawi at clinics offering CTX prophylaxis had significantly reduced mortality during the first 6 months of ART. This additional intervention may have the potential to improve the lives of patients on ART, because CTX is readily available and relatively inexpensive and can, in principle, be easily introduced into ART delivery programs.

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    • "Cotrimoxazole prophylaxis has been shown to reduce morbidity and mortality in HIV-infected adults and children [1] [2] [3] [4] [5]. The World Health Organization (WHO) guidelines issued in 2006 recommend daily cotrimoxazole prophylactic treatment (CPT) for HIV-infected adults and HIV-infected pregnant women with CD4 cell counts of less than 350 cells/ í µí¼‡L or WHO clinical stage III or IV [6]. "
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    ABSTRACT: Background. Limited data exist on cotrimoxazole prophylactic treatment (CPT) in pregnant women, including protection against malaria versus standard intermittent preventive therapy with sulfadoxine-pyrimethamine (IPTp). Methods. Using observational data we examined the effect of CPT in HIV-infected pregnant women on malaria during pregnancy, low birth weight and preterm birth using proportional hazards, logistic, and log binomial regression, respectively. We used linear regression to assess effect of CPT on CD4 count. Results. Data from 468 CPT-exposed and 768 CPT-unexposed women were analyzed. CPT was associated with protection against malaria versus IPTp (hazard ratio: 0.35, 95% Confidence Interval (CI): 0.20, 0.60). After adjustment for time period this effect was not statistically significant (adjusted hazard ratio: 0.66, 95% CI: 0.28, 1.52). Among women receiving and not receiving CPT, rates of low birth weight (7.1% versus 7.6%) and preterm birth (23.5% versus 23.6%) were similar. CPT was associated with lower CD4 counts 24 weeks postpartum in women receiving (-77.6 cells/ μ L, 95% CI: -125.2, -30.1) and not receiving antiretrovirals (-33.7 cells/ μ L, 95% CI: -58.6, -8.8). Conclusions. Compared to IPTp, CPT provided comparable protection against malaria in HIV-infected pregnant women and against preterm birth or low birth weight. Possible implications of CPT-associated lower CD4 postpartum warrant further examination.
    Infectious Diseases in Obstetrics and Gynecology 12/2013; 2013:340702. DOI:10.1155/2013/340702
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    • "Risk factors for early deaths include low baseline CD4 lymphocyte count, initiation of therapy when already in WHO clinical stage 4, low body mass index and anaemia, with the main responsible diseases being tuberculosis (both diagnosed and undiagnosed), bacterial sepsis, cryptococcal meningitis and Kaposi's sarcoma. Useful interventions to reduce this early mortality that should be implemented either before or simultaneously with initiation of ART include cotrimoxazole preventive therapy (Lowrance et al. 2007), active screening for tuberculosis among high-risk patients such as those with unexplained weight loss and ⁄ or unexplained chronic fever, and screening for those at high risk of cryptococcal meningitis with cryptococcal antigen testing and targeted pre-emptive treatment for those with positive results (Jarvis et al. 2009). "
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