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Co-trimoxazole in people on antiretroviral therapy for HIV – Authors' reply

2015; Elsevier BV; Volume: 2; Issue: 6 Linguagem: Inglês

10.1016/s2352-3018(15)00085-5

2405-4704

Amitabh B. Suthar, Marco Vitória, Meg Doherty,

Tuberculosis Research and Epidemiology

We thank José Alfredo de Sousa Moreira for his interest in our article.1Suthar AB Vitoria MA Nagata JM et al.Co-trimoxazole prophylaxis in adults, including pregnant women, with HIV: a systematic review and meta-analysis.Lancet HIV. 2015; 2: e137-e150Summary Full Text Full Text PDF Scopus (59) Google Scholar Moreira suggested that co-trimoxazole prophylaxis may have benefits beyond prevention of AIDS events in high-income countries, including reductions in non-AIDS events resulting from residual immune dysregulation syndrome and incident tuberculosis. We agree that these plausible benefits require further investigation. If co-trimoxazole is proven effective for these benefits, we welcome research to assess continued use with other key interventions, such as isoniazid preventive therapy and inflammatory reducing drugs in high-income countries. In a Comment linked to our paper, Badri and Moghraby2Badri M Moghraby S Co-trimoxazole prophylaxis: the debates continue.Lancet HIV. 2015; 2: e118-e119Summary Full Text Full Text PDF Scopus (2) Google Scholar suggested that the meta-analysis on initiation among adults with CD4 counts less than 350 cells per μL actually had adults with CD4 counts less than 200 cells per μL. Although most participants in this meta-analysis had advanced HIV disease, mortality was significantly reduced in over 2000 person-years with CD4 counts between 200 cells per μL and 350 cells per μL.3Hoffmann CJ Fielding KL Charalambous S et al.Reducing mortality with cotrimoxazole preventive therapy at initiation of antiretroviral therapy in South Africa.AIDS. 2010; 24: 1709-1716Crossref PubMed Scopus (30) Google Scholar, 4Lim PL Zhou J Ditangco RA et al.the TREAT Asia HIV Observational DatabaseFailure to prescribe pneumocystis prophylaxis is associated with increased mortality, even in the cART era: results from the Treat Asia HIV observational database.J Int AIDS Soc. 2012; 15: 1Crossref PubMed Scopus (25) Google Scholar There was also concern that risk differences and hazard ratios were mixed in the same meta-analysis. For the initiation and discontinuation meta-analyses, hazard ratios were used to determine superiority of co-trimoxazole prophylaxis relative to control. Risk differences were used to evaluate the equivalence of different daily doses and the non-inferiority of co-trimoxazole prophylaxis relative to intermittent treatment of malaria in pregnant women. Risk differences and hazard ratios were not mixed in the same meta-analysis. We hope that the important knowledge gaps identified will be filled before the next co-trimoxazole prophylaxis guideline update. The opinions and statements in this article are those of the authors and do not necessarily represent the official policy, endorsement, or views of WHO. We declare no competing interests. Co-trimoxazole prophylaxis in adults, including pregnant women, with HIV: a systematic review and meta-analysisCo-trimoxazole prophylaxis should be given with ART in people with CD4 counts of 350 cells per μL or lower in low-income and middle-income countries. Co-trimoxazole prophylaxis should be provided irrespective of CD4 count in settings with a high burden of infectious diseases. Pregnant women with HIV in Africa should use co-trimoxazole rather than IPTp to prevent malaria complications in infants. Further research is needed to inform dose optimisation and co-trimoxazole use in the context of expanded ART in different epidemiological settings. Full-Text PDF Co-trimoxazole in people on antiretroviral therapy for HIVI read with great interest the meta-analysis of data on the initiation, discontinuation, and dosing of co-trimoxazole prophylaxis in adults with HIV by study of Suthar and colleagues.1 Their findings reinforce recent WHO recommendations for long-term co-trimoxazole prophylaxis in adults with HIV who are receiving antiretroviral therapy irrespective of CD4 cell count or WHO clinical stage, especially in resource-constrained settings with high prevalences of invasive bacterial diseases and malaria. Full-Text PDF