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Cotrimoxazole Prophylaxis Reduced the Early Mortality of HIV-infected Patients on ART in Malawi
David Lowrance*1, S Makombe2, A Harries2,3,4, A Harries2,3,4, A Harries2,3,4, J Yu5, J Aberle-Grasse6, O Eiger6, R Shiraishi1, B Marston1, T Ellerbrock1, and E Libamba2
1Global AIDS Prgm, CDC, Atlanta, GA, US; 2Ministry of Hlth, Lilongwe, Malawi; 3Family Hlth Intl, Arlington, VA, US; 4London Sch of Hygiene and Tropical Med, UK; 5Taiwan Med Mission, Mzuzu Central Hosp, Malawi; and 6Global AIDS Prgm, CDC Malawi, Lilongwe
Background:
High early mortality has been observed in
a number of ART programs in Sub-Saharan Africa. Cotrimoxazole (CTX) prophylaxis
has
been associated with a 25 to 46% reduction in mortality of HIV-infected
individuals in Sub-Saharan Africa who are not on ART, even in areas with high
rates of bacterial resistance to the antibiotic. However, the effect of CTX
prophylaxis on the mortality of patients on ART in sub-Saharan Africa is currently unknown.
Methods:
At the time of the study, Malawi was
providing ART to adult patients with WHO stage III or IV or CD4 cell counts <200.
There was no national policy on provision of CTX to ART patients. We examined the
differences in mortality during the first 6 months of ART between adult patients
at 5 ART clinics that routinely offered CTX and 6 clinics that were similar
with respect to patient burden, location, and level of financial support, but did
not provide CTX. Abstraction was completed for 1295 medical
records; after selecting patients who met the study criteria, data from 1050
records (573 patients who received CTX and 477 who did not) were analyzed.
Results: The mean age of patients at the time of ART initiation
was 38 and 37 years for the CTX and non-CTX groups, respectively (range 15 to
71 years). In both groups, 62% of patients were female. The CTX group had a
significantly higher percentage of patients with CD4+ cell count <200
cells/mm3 as the indication for ART (19% vs 7%, p <0.0001), and either prior or active TB at the time of ART
initiation (14% vs 8%, p = 0.003).
There was no difference in the percentage of patients with WHO stage 3 or 4 as
ART indication. Compared with the non-CTX group, the CTX group experienced a
41% reduction in 6-month mortality risk (11.6% vs 19.6%, p <0.0001). Log-rank tests showed significant improvement
in Kaplan-Meier survival probabilities for the CTX group (p = 0.0011). A survival difference was apparent as early
as 40 to 45 days after ART initiation. Overall, 11% and 16% of patients
defaulted in CTX and non-CTX groups, respectively.
Conclusions: CTX prophylaxis was associated with a mortality
reduction of 41% during the first 6 months of ART in patients in Malawi. In
this and other resource-limited settings, CTX prophylaxis could significantly
improve the survival of patients on ART because CTX is readily available, comparatively
cheap, and has a major impact on mortality during the first 6 months of ART.
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