Why is CTX prophylaxis important in people living with HIV? • It is used for the prevention and control of a range of infections in people living with HIV like gastrointestinal diseases, toxoplasma gondii, pneumocystis carinii pneumonia and malaria • Prevents unnecessary deaths in people living with HIV Who is eligible? Children: • HIV exposed infants born to mothers living with HIV must receive CTX prophylaxis starting 6 weeks after birth • In HIV infected children under 1 year of age CTX is indicated regardless of CD4 cell count or clinical status HIV positive patients (adolescents and adults): • All symptomatic people with mild, advanced or severe HIV disease (WHO clinical staging 2, 3 or 4) • All patients with a CD4 count < 200mm3 • All patients co infected with tuberculosis irrespective of the CD4 count All patients who fulfill the eligibility criteria should be started on CTX prophylaxis immediately Who is not eligible for CTX prophylaxis? • History of adverse reaction to cotrimoxazole and other sulphur drugs • Steven Johnson syndrome • Porphyria • Renal and hepatic insufficiency • Haematological toxicity • Glucose 6 dehydrogenase deficiency How to introduce CTX? • Start CTX first and initiate anti retroviral therapy two weeks later • In TB patients co infected with HIV, start with TB treatment first, followed by CTX and ART according to guidelines CTX Dosage for Children Alternative drug to CTX • Children: Dapsone 2mg/kg once daily (dose range 1-2 mg) • Adults: Dapsone 100mg per day (dose range 50-100 mg) What are the side effects of CTX? Mild: Headache, rash, dry desquamation, nausea and vomiting Moderate: Blood disorders, mucosal ulceration, damage to the kidney and liver Severe: Exfoliative dermatitis, severe skin blistering - Steven Johnson Syndrome, moist desquamation How do you manage CTX side effects? Mild: continue CTX prophylaxis with careful follow up and provide symptomatic treatment such as antihistamines Moderate: CTX prophylaxis should be discontinued until adverse effects, resolved completely (usually two weeks), reintroduction can be considered Severe: Cotrimoxazole should be permanently discontinued and alternative treatment given When should CTX prophylaxis be stopped? Adolescents and adults: Recovery related to ART with a CD4 > 200/mm after at least six months. If there is evidence of good clinical response to ART with absence of clinical symptoms and good adherence to ART HIV infected children: Maintain on CTX prophylaxis if ART is not given HIV infected children on ART: Stop CTX only when there is evidence of immune reconstitution, i.e 18 months or older with CD4 count of > 15% on two occasions no less than three months apart HIV exposed children: CTX should be continued until HIV infection can be excluded by HIV antibody testing beyond 18 months of age, or virological testing before 18 months of age. Discontinue CTX prophylaxis only after HIV infection is excluded and infant no longer at risk of acquiring HIV through breastfeeding 200 mg/40mg per 5 m L Suspension ANTIBACTERIAL Cotrimoxazole Prophylaxis in Patients Co-infected with TB and HIV FREQUENCY - ONCE A DAY Side Effect Anti-TB Anti-Retroviral Rash Rifampicin Streptomycin Ethambutol Isoniazid Pyrazinamide Nevirapine Efavirenz Nausea and Vomiting Rifampicin Zidovudine Didonosine Abacavir Lopinavir/Ritonavir Ritonavir Indinavir Hepatoxicity Isoniazid Rifampicin Pyrazinamide Nevirapine Efavirenz Ritonavir Nephrotoxicity Streptomycin Rifampicin (rare) Tenofovir Indinavir Anemia Pyrazinamide (rare) Rifampicin (rare) Zidovudine What are the common side effects of CTX with anti-TB drugs and ARVs? Weight Cotrimoxazole (ml) < 5kg 2½ ml 5-9 kg 5 ml 10-14.9 kg 7½ ml 15-21.9 kg 10 ml or one (480 mg) single strength tablet > 22 kg 15 ml or 1½ - 2 single strength tablets This material has been developed by URC/TASC-II TB project with funding from Pepfar CTX Dosage for Adults • One double strength (800mg/160mg) tablet OR two single strength (400mg/80mg) tablets once daily • Total daily dose 960mg
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Why is CTX prophylaxis important in people living with HIV?• It isusedforthepreventionandcontrolofa rangeof infections inpeople livingwithHIV like gastrointestinal diseases, toxoplasma gondii, pneumocystis carinii pneumonia and malaria
• Prevents unnecessary deaths in people living withHIV
Who is eligible?Children:• HIV exposed infants born to mothers living with HIV must receive CTX prophylaxisstarting6weeksafterbirth
• InHIVinfectedchildrenunder1yearofageCTXisindicatedregardlessof CD4cellcountorclinicalstatus
HIV positive patients (adolescents and adults):• All symptomaticpeoplewithmild, advancedor severeHIVdisease (WHO clinicalstaging2,3or4)
• AllpatientswithaCD4count<200mm3
• AllpatientscoinfectedwithtuberculosisirrespectiveoftheCD4count
All patients who fulfill the eligibility criteria should be started on CTX prophylaxis immediately
Who is not eligible for CTX prophylaxis?• Historyofadversereactiontocotrimoxazoleandothersulphurdrugs• StevenJohnsonsyndrome• Porphyria• Renalandhepaticinsufficiency• Haematologicaltoxicity• Glucose6dehydrogenasedeficiency
How to introduce CTX?• StartCTXfirstandinitiateantiretroviraltherapytwoweekslater
• InTBpatientscoinfectedwithHIV,startwithTBtreatmentfirst,followedby CTXandARTaccordingtoguidelines
CTX Dosage for Children
Alternative drug to CTX• Children:Dapsone2mg/kgoncedaily(doserange1-2mg)• Adults:Dapsone100mgperday(doserange50-100mg)
What are the side effects of CTX?
Mild:Headache,rash,drydesquamation,nauseaandvomiting
Moderate:Blooddisorders,mucosalulceration,damagetothekidneyandliver
Severe:Exfoliativedermatitis,severeskinblistering-StevenJohnsonSyndrome,moistdesquamation
How do you manage CTX side effects?Mild:continueCTXprophylaxiswithcarefulfollowupandprovidesymptomatictreatmentsuchasantihistamines
Moderate: CTXprophylaxisshouldbediscontinueduntiladverseeffects,resolvedcompletely(usuallytwoweeks),reintroductioncanbeconsidered
Severe: Cotrimoxazole shouldbepermanentlydiscontinuedandalternativetreatmentgiven
When should CTX prophylaxis be stopped?Adolescents and adults:Recovery related to ART with a CD4 > 200/mm afterat least six months. If there is evidence of good clinicalresponsetoARTwithabsenceofclinicalsymptomsandgoodadherencetoART
HIV infected children:MaintainonCTXprophylaxisifARTisnotgiven
HIV infected children on ART:Stop CTX only when there is evidence of immunereconstitution,i.e18monthsorolderwithCD4countof>15%ontwooccasionsnolessthanthreemonthsapart
HIV exposed children:CTXshouldbecontinueduntilHIVinfectioncanbeexcludedbyHIVantibodytestingbeyond18monthsofage,orvirologicaltestingbefore18monthsofage. Discontinue CTX prophylaxis only after HIV infection is excluded andinfantnolongeratriskofacquiringHIVthroughbreastfeeding
200 mg/40mg per 5 mLSuspension
ANTIBACTERIAL
Cotrimoxazole Prophylaxis in Patients Co-infected with TB and HIV
FREQUENCY - ONCE A DAY
Side Effect Anti-TB Anti-Retroviral
Rash
RifampicinStreptomycinEthambutol
IsoniazidPyrazinamide
NevirapineEfavirenz
Nausea and Vomiting
Rifampicin
ZidovudineDidonosine
AbacavirLopinavir/Ritonavir
RitonavirIndinavir
HepatoxicityIsoniazid
RifampicinPyrazinamide
NevirapineEfavirenzRitonavir
NephrotoxicityStreptomycin
Rifampicin(rare)TenofovirIndinavir
AnemiaPyrazinamide(rare)
Rifampicin(rare)Zidovudine
What are the common side effects of CTX with anti-TB drugs and ARVs?
Weight Cotrimoxazole (ml)
<5kg 2½ml
5-9kg 5ml
10-14.9kg 7½ml
15-21.9kg10mlorone(480mg)singlestrengthtablet
>22kg15mlor1½-2single
strengthtablets
This material has been developed by URC/TASC-II TB project with funding from Pepfar
CTX Dosage for Adults• One double strength (800mg/160mg) tablet OR two single strength (400mg/80mg)tabletsoncedaily
• Totaldailydose960mg
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