Co-trimoxazole prophylactic therapy in persons with HIV and TB coinfection

Prophylaxis

Recommendations

Commencing primary CPT

Initiated in PLHIV with:

•      CD4 count < 350/mm³ OR
• PLHIV with Pulmonary TB or Extra-Pulmonary TB 

Commencing secondary CPT

For all patients who have completed successful treatment for Pneumocystis pneumonia (PCP)

Timing the initiation of Co- trimoxazole in relation to initiating ART

•     Start CPT first
•      Start Antiretroviral Therapy (ART) after starting CPT or as soon as CPT is tolerated, and the patient has completed the “preparedness phase “of counselling

Dosage of Co-trimoxazole in adults and adolescents

One double-strength tablet (or two single-strength) tablets once daily – total daily dose of 960 mg (800 mg Sulfamethoxazole (SMX) + 160 mg Trimethoprim (TMP))

Co-trimoxazole for pregnant and breastfeeding women

•      Women who fulfil the criteria for CPT should continue it throughout pregnancy
•      If a woman requires CPT during pregnancy, it should be started regardless of the stage of pregnancy
•      Breastfeeding women should continue CPT where indicated

Patients allergic to sulpha- based medications

•     Use dapsone 100 mg per day
•      Co-trimoxazole desensitisation may be attempted but not in patients with a previous severe reaction to co-trimoxazole or other sulpha- containing drugs

Monitoring

No specific laboratory monitoring is required in patients receiving co-cotrimoxazole the a 

Discontinuation of CPT (primary or secondary)

When CD4 count > 350/mm³ on two different occasions 6 months apart with an ascending trend and devoid of any WHO clinical stage 3 and 4 conditions

Group

When to start Co-trimoxazole?

When to discontinue CPT prophylaxis?

Notes

All HIV- exposed infants/ children

From 6 weeks of age (or at first encounter with health services)

HIV infection has been reliably excluded by a negative antibody test at 18 months, regardless of ARV initiation. 

In infants confirmed to be HIV infected, CPT should be continued till 5 years of age

All HIV- infected infants and children up to 5 years 

Irrespective of WHO stage or CD4 counts or CD4%

At 5 years of age, when clinical or immunological indicators confirm restoration of the immune system for more than 6 months i.e. in a child > 5 years of age with a WHO T- stage 1 or 2 and CD4 count of > 350 cell/mm³ on two occasions not less than 3 months apart

Children with history of severe adverse reactions (grade 4 reaction) to co-trimoxazole or other sulpha drugs as well as children with glucose-6-phosphate dehydrogenase deficiency (G6PD) should not be initiated on CPT. The alternative drug, in this case, is Dapsone 2 mg/kg once daily (not to exceed 100 mg/day) orally.

All HIV-infected
children > 5 years of age

WHO Stage 3 and 4 irrespective of CD4
OR
CD4 < 350 cells/mm³ irrespective of WHO staging

When clinical or immunological indicators confirm restoration of the immune system for more than 6 months i.e. in a child > 5 years of age with a WHO T- stage 1 or 2 and CD4 count of > 350 cell/mm³ on two occasions not less than 3 months apart

As secondary prophylaxis

After completion of treatment for PCP

< 5 years old: Do not stop
> 5 years old: may consider stopping as per the adult guidelines

Weight (kg)

Approx. Age

Cotrimoxazole once a day

Syrup 5ml (40 TMP/200 SMX)

Child Tablet (20 TMP, 100 SMX)

Single strength adult (80 TMP/ 400 SMX)

Double strength adult tablet (160 TMP/800 SMX)

<5

6 weeks – 2 months

2.5 ml

1 tablet

-

-

5-10

2-12 months

5 ml

2 tablets

½ tablet

-

10-15

1-2 years

7.5 ml

3 tablets

½ tablet

-

15-22

2-5 years

10 ml

4 tablets

1 tablet

½ tablet

>22

>5 years

15 ml

-

1 ½ tablet

½ to 1 tablet depending on weight

Question

Answer 1

Answer 2

Answer 3

Answer 4

Correct answer

Explanation

Page ID

Part of pre-test

Part of post-test

Which of the following statements is true?

A PLHIV diagnosed with PTB or EPTB should be given CPT.

A CLHIV diagnosed with PTB or EPTB should be given CTP.

An infant diagnosed with TB and is born to a mother with HIV should be given CPT.

All the above

 4

All the statements are true.

Yes

Yes