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
