Cotrimoxazole Preventive Therapy Research Articles

The White and the Three-Letter Plague: Integration of TB and HIV Care in Sub-Saharan Africa

Although sub-Saharan Africa contains approximately 12% of the world’s population, it hosts an estimated 68% of all living HIV-infected people (22.5 million persons) and 30% of annual cases of TB (4.4 million persons). In countries with an extended epidemic of both HIV and TB, both infections commonly affect the same individuals. However, TB care services (WHO’s Directly Observed Therapy Short Course) and HIV care services essentially function as separate vertical programs. In 2004, in an effort to improve the management and control of TB and HIV, WHO produced an Interim Policy on collaborative TB/HIV Activities with a range of measures to improve the integration of TB care into HIV treatment programs (intensified TB case finding, isoniazid preventive therapy and TB infection control in healthcare settings) and the integration of HIV care into TB treatment programs (HIV testing and counseling, HIV prevention, co-trimoxazole preventive therapy, HIV/AIDS care and support, and antiretroviral therapy). In this review, we describe and critically discuss the evidence relating to the implementation of the proposed collaborative activities in sub-Saharan Africa.

HIV-related pulmonary disorders: practice issues

Pulmonary disease is the major cause of morbidity and mortality in infants and children infected with the human immunodeficiency virus (HIV). Diagnosis and management is often difficult in the resource-limited setting, especially as most HIV-related pulmonary disease presents in infancy or early childhood. Knowledge of the causes of pulmonary disease in HIV-infected children in that setting has improved considerably over the last decade, as has the availability of effective treatment for all HIV-infected children, such as cotrimoxazole preventive therapy and antiretroviral therapy. Important causes of acute bacterial pneumonia in HIV-infected children include bacteria such as pneumococci, gram-negatives and staphylococci. Pneumocystis pneumonia is particularly common in HIV-infected infants and a common cause of death. Cytomegalovirus is also found frequently in infants with pneumonia, often as a co-infection with PcP. Tuberculosis (TB) is increasingly recognised as a common cause of acute pneumonia as well as chronic pulmonary disease in regions endemic for TB/HIV. Other important causes of chronic lung disease in HIV-infected children include lymphocytic interstitial pneumonitis and bronchiectasis. This review aims to address practical issues that health workers often face in the management of acute or chronic pulmonary disease presenting in HIV-infected children in the resource-limited setting.

Joint tuberculosis/HIV services in Malawi: progress, challenges and the way forward

Joint tuberculosis/HIV services in Malawi: progress, challenges and the way forward

Lessons from TB/HIV integration in Cambodia

Background Cambodia ranks 22nd among countries with the highest burden of TB. (1) WHO estimates that in 2004, Cambodia's incidence rate for all forms of TB was 510/100 000, and for smear-positive pulmonary TB, 226/100 000. (1) Although HIV prevalence among adults aged 15-49 years has decreased from 3% (1998) to 1.9% (2003), Cambodia continues to have one of the most serious documented epidemics in Asia, with an estimated 123 100 adults living with HIV/AIDS. (2) Given an estimated 64% of Cambodians infected with M. tuberculosis, (3) the overlap of the TB and HIV epidemics is inevitable. HIV prevalence among TB patients has increased from 2.5% (1995) (4) to 10% (2005). (5,6) As discussed in the base paper by Laserson & Wells, the impact of HIV-associated tuberculosis must be addressed by scaling up collaborative activities. In response to these dual epidemics and separate national programmes to deal with each disease, the Cambodian Ministry of Health established the subcommittee on TB/HIV in 1999 and two frameworks in 2002, the Framework for TB/HIV in Cambodia and the Continuum of Care (COC) for People Living with HIV/AIDS Operational Framework. (7) In line with these policy documents, the National TB/HIV Subcommittee selected four pilot sites in 2003 (Phnom Penh, Battambang, Banteay Mean Chey and Sihanouk Ville) for rapid TB/HIV programme development. It designated the international partners Japan International Cooperation Agency, Family Health International/Gorgas TB Initiative, CDC/Global AIDS Program and WHO to provide technical assistance and support. In 2005, the national TB and HIV/AIDS programmes released a joint statement and standard operating procedures (SOP) for testing of TB/HIV. Under the COC framework and the WHO 3x5 Initiative, access to ART for HIV-infected TB patients became available. The National TB Programme (NTP) has called for expanded access to ART for all eligible HIV-infected TB patients. Since 2003, the NTP has strengthened surveillance of co-infection among TB patients through national surveys. District TB registers were revised to capture HIV information, and patient referrals are made to voluntary counselling and testing (VCT) centres, home-based care programmes and ART clinics where co-trimoxazole preventive therapy is provided. Results of integration The impact of HIV co-infection on TB case fatality is evident in surveillance data. As the rate of co-infection rises, so does the reported death rate among sputum smear-positive patients. (8) Early indicators of TB/HIV programme linkage among the four pilot sites show important variations. While each site differs in size and conditions, the capacity to test TB patients for HIV co-infection is less uniform across sites than the ability to screen for TB among newly diagnosed HIV-positive patients. In 2005, the sites were able to screen from 70-100% of all newly diagnosed HIV-infected persons, but only 14-83% of TB patients were tested for HIV co-infection (NTP surveillance data). (9) The rate of active disease found upon screening ranged from 9% to 26%. IPT is provided on a trial basis at only one site after routine sputum culture to rule out active TB. To date, nearly 200 persons have received IPT and are being followed upon completion of a 9-month regimen. (10) Lessons learned From the TB-control programme perspective, the main challenges to TB/HIV co-management and linkage can be divided between issues regarding health systems/infrastructure and human resource capacities. The first set of issues reflects where the patient enters the health service. Routine TB screening is accessible for HIV-infected persons through a well-established, decentralized infrastructure for TB diagnosis and treatment. The main barrier relates to limited access to culture for diagnosing sputum smear-negative disease, and a lesser extent, to tools to diagnose extra-pulmonary TB. …

Costs of measures to control tuberculosis/HIV in public primary care facilities in Cape Town, South Africa

To measure the costs and estimate the cost-effectiveness of the ProTEST package of tuberculosis/human immunodeficiency virus (TB/HIV) interventions in primary health care facilities in Cape Town, South Africa. We collected annual cost data retrospectively using ingredients-based costing in three primary care facilities and estimated the cost per HIV infection averted and the cost per TB case prevented. The range of costs per person for the ProTEST interventions in the three facilities were: US$ 7-11 for voluntary counselling and testing (VCT), US$ 81-166 for detecting a TB case, US$ 92-183 for completing isoniazid preventive therapy (IPT) and US$ 20-44 for completing six months of cotrimoxazole preventive therapy. The estimated cost per HIV infection averted by VCT was US$ 67-112. The cost per TB case prevented by VCT (through preventing HIV) was US$ 129-215, by intensified case finding was US$ 323-664 and by IPT was US$ 486-962. Sensitivity analysis showed that the use of chest X-rays for IPT screening decreases the cost-effectiveness of IPT in preventing TB cases by 36%. IPT screening with or without tuberculin purified protein derivative screening was almost equally cost-effective. We conclude that the ProTEST package is cost saving. Despite moderate adherence, linking prevention and care interventions for TB and HIV resulted in the estimated costs of preventing TB being less than previous estimates of costs of treating it. VCT was less expensive than previously reported in Africa.

Pneumocystis carinii pneumonia in HIV/AIDS patients at an urban district hospital in Kenya.

Pneumocystis carinii pneumonia has generally been regarded to be an uncommon opportunistic infection in HIV infected individuals in sub-Saharan Africa. The reason for this has not been clear but postulates included a lack of suitable pathogenic types in the African environment, diagnostic difficulties and the more commonly held belief that African HIV infected individuals were dying early from common non-opportunistic pathogens before severe degrees of immunosuppression occured. Recently a trend has emerged at the Mbagathi district hospital whereby an increasing number of HIV infected patients are empirically treated for Pneumocystis carinii pneumonia (PCP) based on clinical and radiological features. To determine the prevalence of PCP and clinical outcomes of HIV infected patients presenting at the Mbagathi District Hospital, Nairobi with the presumptive diagnosis of PCP. Mbagathi District Hospital, a 169-bed public hospital in Nairobi, Kenya. Patients presenting with a sub-acute onset of cough and dyspnoea were eligible for the study if they were found to have bilateral pulmonary shadows and had negative sputum smears for AFBS. Consenting patients who had no contraindication to fiberoptic bronchoscopy had a clinical evaluation which was followed with a fiberoptic bronchoscopy procedure where bronchoalveolar lavage fluid (BALF) was obtained. BALF was examined for cysts of P. carinii using toluidine blue stain and immunofluorescent antibody test (IFAT). BALF was also processed for fungi, bacteria and mycobacteria using routine procedures. Standard treatment with high dose cotrimoxazole was offered to all patients who were then followed up until discharge from hospital or death whichever came first. Between June 1999 and August 2000 a total of 63 patients were referred for bronchoscopy. Of these four declined to undergo the fiberoptic bronchoscopy procedure, four died before the procedure could be done, one was judged too sick to undergo the procedure and three had been on cotrimoxazole for longer than five days. Thus 51 patients underwent bronchoscopy. Pneumocystis carinii stain was positive in 19 (37.2%) while death occured in 16 (31.4%) of the 51 patients. There were more deaths in those without PCP but this difference was not statistically significant (odds ratio 0.68 (95% CI 0.35-1.32; P=0.2). PCP was found to be common in HIV infected patients presenting with clinical and radiological features of the disease. The mortality rate for patients with a presumptive diagnosis of PCP is high. This study suggests that cotrimoxazole preventive therapy may be a useful intervention in symptomatic HIV infected patients in Kenya for the prevention of PCP and may avert deaths from this disease.

Predictors of Time to Viral Load Suppression of Adult PLWHIV on ART in Arba Minch General Hospital: A Follow up Study.

Access to antiretroviral drugs for all infected persons in need is a global health priority. The viral load and CD4 counts should be monitored regularly. The plasma viral load should be reduced by as much and for as short as possible. Identifying factors that predict time to viral load suppression of patients on antiretroviral therapy regimens is thus vital to optimizing therapeutic success. Therefore, this study aimed to estimate the time to viral load suppression and identify predictors of time to viral load suppression of patients on antiretroviral therapy at Arba Minch general Hospital. This study was observational study using data abstracted from medical records, patient interviews and laboratory work-up during 6 months of follow up. The data were collected from 152 naive to anti-retro viral drug patients. The univariable and multivariable Cox proportional hazard regression analyses were done to identify predictors. The median survival time of viral load suppression among adult patients living with HIV was 3 months with 95% CI (2.68, 3.32). The Cox-proportional hazard analysis shows baseline CD4 count of <200cells/mm3 (AHR=0.683, CI:0.471, 0.990), baseline viral load of <10,000 copies/ml (AHR=4.135, CI:1.835, 9.317), having baseline Cotrimoxazole preventive therapy (AHR=1.997, CI:1.108, 3.600), having baseline Isoniazid preventive therapy (AHR=3.085, CI:1.721, 5.529) and good adherence level to ART (AHR=2.648, CI: 1.202, 5.834) significantly predict the time to viral load suppression. Early improvement and maintenance of CD4 count and viral load to normal level should be attained through streamlining and strengthening monitoring and counseling of patients on adherence to ART, Cotrimoxazole and Isoniazid drugs.