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The objective of Co-trimoxazole Preventive Therapy (CPT) is to reduce morbidity and mortality among People Living with HIV (PLHIV) from opportunistic infections.

CPT is effective in preventing a range of bacterial fungal and protozoal opportunistic infections in PLHIV including Pneumocystis Pneumonia (PCP) caused by the fungus Pneumocystis jirovecii, toxoplasmosis, bacterial pneumonias, nocardiasis and isosporiasis. Hence, CPT is a standard component of HIV care.

Co-trimoxazole is a combination of two drugs – Sulfamethoxazole (SMX) and Trimethoprim (TMP). A single-strength tablet contains 400 mg SMX and 80 mg TMP

There are two types of CPT prophylaxis:

1. Primary prophylaxis - Aims to avoid the first occurrence of infection

2. Secondary prophylaxis - Aims to avoid the recurrence of infection after successful treatment 

Table 1: CPT for Adults and Adolescents living with HIV

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

Table 2: CPT in Infants/children exposed to/living with HIV

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

 

Table 3: Weight bands and dosage of CPT in children

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

Dispensation of CPT: The Medical Officer at the ART Centre assesses the patient and prescribes CPT. The tablets are dispensed by the pharmacist at the ART centre.

 

References

 

Assessment

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
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Comments

Mariyam Thu, 15/09/2022 - 14:47

Cotrimoxazole is a combination of two drugs – Sulfamethoxazole and Trimethoprim. It is effective in preventing a range of bacterial fungal and protozoal opportunistic infections in PLHIV including Pneumocystis pneumonia (PCP) caused by the fungus Pneumocystis jirovecii, Toxoplasmosis, Bacterial pneumonias, Nocardiasis and Isosporiasis.

Cotrimoxazole Preventive Therapy (CPT) aims to avoid either the first occurrence of these infections (primary prophylaxis) or their recurrence (secondary prophylaxis)

PLHIV/CLHIV with Pulmonary TB classifies as WHO clinical stage 3 and PLHIV with Extra-Pulmonary TB classifies as WHO clinical stage 4

 

Co-trimoxazole Preventive Therapy (CPT) for Adults and Adolescents living with HIV:

Prophylaxis

Recommendations

Commencing primary CPT

Co-trimoxazole Prophylaxis must be initiated in PLHIV with:

  • CD4 count < 350/mm3 OR
  • WHO clinical stage 3 and 4

PLHIV with Pulmonary TB classifies as WHO clinical stage 3

PLHIV with Extra-Pulmonary TB classifies as WHO clinical stage 4

Commencing secondary CPT

For all patients who have completed successful treatment for PCP

 

Timing the initiation of Co- trimoxazole in relation to initiating ART
    • Start co-trimoxazole prophylaxis first
    • Start ART after starting co-trimoxazole 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 SMZ + 160 mg TMP)

Co-trimoxazole for pregnant and breastfeeding women
    • Women, who fulfil the criteria for CPT, should continue on 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
    • Dapsone 100 mg per day.
    • Co-trimoxazole desensitization 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- trimoxazole

Discontinuation of co- trimoxazole prophylaxis (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

Cotrimoxazole Preventive therapy in Infants/Children exposed to/living with HIV:

Unlike adults CPT is indicated for infants exposed to HIV who are uninfected (HIV Exposed Infant/Child = Infant/Child born to HIV infected woman, is reliably excluded or confirmed with HIV status and is no longer exposed to HIV through breast feeding)

  Group

   When to start Cotrimoxazole?

   When to discontinue CPT?

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

All HIV- infected infants and children up to 5 year of age

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

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

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