Effect Of Cotrimoxazole Prophylaxis Research Articles

Asymptomatic malaria parasitaemia among HIV infected children and adolescents

Background: Malaria manifests with life-threatening manifestations resulting in hospital admissions and sometimes death may ensue. This is more devastating among children due to high susceptibility resulting from impaired immune system following severe malaria. Human immunodeficiency virus (HIV) coinfection with malaria further compromises the immune system and increases the vulnerability. The effect of co-trimoxazole prophylaxis in curtailing malaria has not being well evaluated in our environment where both malaria and HIV are endemic. This study sets out to determine the magnitude of asymptomatic malaria among HIV-infected children and adolescents receiving care at our facility. Study Design: This was a descriptive cross-sectional study. Materials and Methods: A prospective study among HIV-infected children aged 2–18 years was enrolled in our care. Nonprobability convenience sampling was used to recruit individuals who fulfilled the criteria. Questionnaire and patients' medical records were used to gather some data. A sample was taken for malaria parasite microscopy. The analysis was done using the Statistical Package for the Social Sciences version 20. Categorical variables were presented as percentages and association assessed using Chi-square test, whereas continuous variables were presented as mean and standard deviation, and the association between two means was checked using Student's t-test. Results: The mean age of the study population is 7.02 ± 2.97 years. Of the 420 participants in this study, 92 (45.7%) had confirmed malaria. There was no significant difference in the gender, age groups, and viral loads of patients with malaria. Conclusion: There is a high prevalence of malaria coinfection with HIV in this study.

Effect of co-trimoxazole prophylaxis on morbidity and mortality of HIV-exposed, HIV-uninfected infants in South Africa: a randomised controlled, non-inferiority trial

WHO guidelines recommend co-trimoxazole prophylaxis for HIV-exposed, HIV-uninfected infants. These guidelines date back to an era in which HIV testing of infants was impossible and mothers had poor access to antiretroviral treatment. To determine whether this guideline requires revision in the current era of effective prevention of mother-to-child transmission and early infant diagnosis programmes, we aimed to investigate whether receiving no co-trimoxazole prophylaxis is inferior to receiving co-trimoxazole prophylaxis in the resulting incidence of grade 3 or 4 common childhood illnesses or mortality in breastfed HIV-exposed, HIV-uninfected infants. We investigated our aim in a randomised controlled, non-inferiority trial. We enrolled the HIV-negative infants of mothers living with HIV who were actively involved in transmission prevention programmes in two clinics in Durban, South Africa. Infants were included in the study if they were breastfeeding at the screening and enrolment visits, and their mother was planning to breastfeed for at least 6 months; were a singleton birth and had a birthweight of 2 kg or more; had no clinically observed genetic disorders; and had no serious illnesses and had not received antibiotics or traditional medications (such as herbal remedies). Infants were randomly assigned (1:1) to receive co-trimoxazole or no co-trimoxazole. In the co-trimoxazole group, infants received the drug until all exposure to HIV had ceased (ie, 6 weeks after last exposure to breastmilk) and the infant was confirmed to be uninfected with HIV. The drug was administered by mothers in once-daily regimens of 20 mg trimethoprim and 100 mg sulfamethoxazole orally (age <6 months or bodyweight <5 kg), or 40 mg trimethoprim and 200 mg sulfamethoxazole orally (age >6 months or bodyweight >5 kg). Clinical and laboratory staff always remained masked to group assignment, but mothers and study counsellors were not. Infants and their mothers attended study visits at ages 6 weeks (for enrolment and randomisation), 10 weeks, 14 weeks, and then monthly from 4 to 12 months. Our primary outcome was the incidence of grade 3 or 4 common childhood illnesses (pneumonia or diarrhoea) or mortality in breastfed HIV-exposed, HIV-uninfected infants by age 12 months. A non-inferiority bound of 5% was used. The study is registered with the Pan African Clinical Trials Registry, number PACTR201311000621110, and the South African National Clinical Trials Registry, number DOH-27-0614-4728. We screened 1570 mother-child pairs for study enrolment, from whom (78%) eligible infants were enrolled into the study between Oct 16, 2013, and May 23, 2018. Of the infants enrolled, 611 (50%) were randomly assigned to the co-trimoxazole group and 609 (50%) were randomly assigned to the no co-trimoxazole group. One (<1%) infant in the no co-trimoxazole group was excluded from the analysis of the final outcomes for having received traditional medicine (which only became apparent after randomisation); therefore, 611 (50%) infants in the co-trimoxazole group and 608 (50%) infants in the no co-trimoxazole group were included in the final intention-to-treat analysis. 136 (22%) infants in the co-trimoxazole group and 139 (23%) infants in the no co-trimoxazole group did not complete the 12-month study visit, predominantly because of loss to follow-up (93 [15%] infants in the co-trimoxazole group; 90 [15%] infants in the no co-trimoxazole group). The cumulative probability of the composite primary outcome was 0·114 (95% CI 0·076 to 0·147; 49 events) in the co-trimoxazole group versus 0·0795 (0·044 to 0·115; 39 events) in the no co-trimoxazole group. The risk difference (no co-trimoxazole group minus co-trimoxazole group) was -0·0319 (-0·075 to 0·011), meaning that the risk was around 3 percentage points lower in the no co-trimoxazole group on the additive scale. We can conclude that no co-trimoxazole is not inferior to daily co-trimoxazole among breastfed HIV-exposed, HIV-uninfected infants whose mothers are accessing a prevention of mother-to-child transmission programme in an area unaffected by malaria. We therefore believe that WHO should revise the co-trimoxazole guidelines for HIV-exposed, HIV-uninfected infants in areas unaffected by malaria. HIV Prevention Research Unit of the South African Medical Research Council and the Family Larsson-Rosenquist Foundation.

Effects of cotrimoxazole prophylaxis on Talaromyces marneffei infection in HIV/AIDS patients receiving antiretroviral therapy: a retrospective cohort study

ABSTRACT The dimorphic fungus Talaromyces marneffei (TM) is a common cause of HIV-associated opportunistic infections in Southeast Asia. Cotrimoxazole (CTX) inhibits folic acid synthesis which is important for the survival of many bacteria, protozoa, and fungi and has been used to prevent several opportunistic infections among HIV/AIDS patients. We question whether CTX is effective in preventing TM infection. To investigate this question, we conducted an 11-year (2005–2016) retrospective observational cohort study of all patients on the Chinese national antiretroviral therapy (ART) programme in Guangxi, a province with high HIV and TM burden in China. Survival analysis was conducted to investigate TM cumulative incidence, and Cox regression and propensity score matching (PSM) were used to evaluate the effect of CTX on TM incidence. Of the 3359 eligible individuals contributing 10,504.66 person-years of follow-up, 81.81% received CTX within 6 months after ART initiation, and 4.73% developed TM infection, contributing 15.14/1,000 person-year TM incidence rate. CTX patients had a significantly lower incidence of TM infection than non-CTX patients (4.11% vs. 7.53%; adjusted hazard ratio (aHR) = 0.50, 95% CI 0.35–0.73). CTX reduced TM incidence in all CD4+ cell subgroups (<50 cells/μL, 50–99 cells/μL, 100–199 cells/μL), with the highest reduction observed in patients with a baseline CD4+ cell count <50 cells/μL in both Cox regression and the PSM analyses. In conclusion, in addition to preventing other HIV-associated opportunistic infections, CTX prophylaxis has the potential to prevent TM infection in HIV/AIDS patients receiving ART.

Effect of cotrimoxazole prophylaxis on malaria occurrence among HIV-infected adults in West Africa: the MALHIV Study.

Cotrimoxazole (CTX) should be given to all HIV-infected adults with mild or severe HIV-disease or those with CD4 counts below 350/mm3 according to 2006 WHO guidelines. We assessed the impact of CTX prophylaxis on the risk of malaria episodes in HIV-1-infected adults from four West African countries with different patterns of malaria transmission. Multicentric cohort study, conducted between September 2007 and March 2010 in four West African cities. Antiretroviral therapy (ART) naïve HIV-infected adults started CTX at enrolment (CTX group) if they had CD4 < 350 cells/mm3 or were at WHO clinical stage ≥2. For patients who did not start CTX at enrolment (non-CTX group) and started CTX afterwards, follow-up was censored at CTX initiation. We used Cox's proportional hazard model to compare the risk of malaria between CTX groups. A total of 514 participants (median CD4 count 238 cells/mm3 ) were followed for a median of 15 months. At enrolment, 347 started CTX, and 261 started ART. During the follow-up, 28 started CTX. The incidence of malaria was 8.7/100 PY (95%CI 6.3-11.5) overall, 5.2/100 PY (95%CI 3.1-8.3) in the CTX group and 15.5/100 PY (95%CI 10.3-22.1) in the non-CTX group. In multivariate analysis, CTX led to a 69% reduction in the risk of malaria (aHR 0.31, 95%CI 0.10-0.90). Patients in the CTX group had an adjusted risk of malaria three times lower than those in the non-CTX group. The prolonged large-scale use of CTX did not blunt the efficacy of CTX to prevent malaria in this region.

Effect of cotrimoxazole prophylaxis on the incidence of malaria in HIV-infected children in 2012, in Abidjan, Côte d'Ivoire: a prospective cohort study.

BackgroundCotrimoxazole prophylaxis has an antimalarial effect which could have an additional protective effect against malaria in HIV-infected children on antiretroviral therapy (ART). We measured the incidence and associated factors of malaria in HIV-infected children on ART and/or cotrimoxazole in Abidjan, Côte d’Ivoire.MethodsAll HIV-infected children <16 years, followed-up in the IeDEA West-African paediatric cohort (pWADA) in Abidjan, were prospectively included from May to August 2012, the rainy season. Children presenting signs suggesting malaria had a thick blood smear and were classified as confirmed or probable malaria. We calculated incidence density rates (IR) per 100 child-years (CY). Risk factors were assessed using a Poisson regression model.ResultsOverall, 1117 children were included, of whom 89 % were ART-treated and 67 % received cotrimoxazole. Overall, there were 51 malaria events occurring in 48 children: 28 confirmed and 23 probable; 94 % were uncomplicated malaria. The overall IR of malaria (confirmed and probable) was 18.3/100 CY (95 % CI: 13.3-23.4), varying from 4.2/100 CY (95 % CI: 1.1-7.3) in children on ART and cotrimoxazole to 57.3/100 CY (95 % CI: 7.1-107.6) for those receiving no treatment at all. In univariate analysis, age <5 years was significantly associated with a 2-fold IR of malaria compared to age >10 years (incidence rate ratio [IRR] = 2.18, 95 % CI: 1.04-4.58). Adjusted for severe immunodeficiency, cotrimoxazole reduced significantly the IR of first malarial episode (adjusted IRR [aIRR] = 0.13, 95 % CI: 0.02-0.69 and aIRR = 0.05, 95 % CI:0.02-0.18 in those off and on ART respectively). Severe immunodeficiency increased significantly the malaria IR (aIRR = 4.03, 95 % CI: 1.55-10.47).When considering the IR of confirmed malaria only, this varied from 2.4/100 CY (95 % CI: 0.0-4.8) in children on ART and cotrimoxazole to 34.4/100 CY (95 % CI: 0.0-73.3) for those receiving no treatment at all. In adjusted analyses, the IR of malaria in children on both cotrimoxazole and ART was significantly reduced (aIRR = 0.05, 95 % CI: 0.01-0.24) compared to those receiving no treatment at all.ConclusionsCotrimoxazole prophylaxis was strongly protective against the incidence of malaria when associated with ART in HIV-infected children. Thus, these drugs should be provided as widely and durably as possible in all HIV-infected children <5 years of age.

Improved survival with co-trimoxazole prophylaxis among people living with HIV/AIDS who initiated antiretroviral treatment in Henan Province, China.

This study aims to evaluate the effect of co-trimoxazole (CTX) prophylaxis on mortality reduction among HIV-infected patients receiving antiretroviral therapy (ART) in Henan Province, China. We conducted a retrospective study. All individuals aged 15 years and older who initiated ART between 2008 and 2010 in Henan Province with completed CTX prophylaxis treatment information were included. The effect of CTX prophylaxis was estimated using Kaplan-Meier survival analysis and multivariate Cox proportional hazard modeling for mortality at 3-months and 12-months after ART initiation. Overall mortality among patients receiving both ART and CTX was nearly double at 3-months after ART initiation compared with that at 12-months (12.4 per 100 PY vs 6.3 per 100 PY, p < 0.01). After adjusting for gender, age, TB history, year of ART initiation and CD4 count at ART initiation, CTX was associated with a significant reduction in 12-month mortality (adjusted hazard ratio (AHR) = 0.65, 95% confidence interval (CI): 0.44-0.95; p = 0.027) compared with persons not receiving CTX. The protective effect was more pronounced in the first 3 months after ART initiation (AHR = 0.53, 95% CI: 0.32-0.89; p = 0.017). CTX prophylaxis together with ART reduced mortality of adult HIV patients during the first 12 months of ART in Henan Province, China. The effect was highest in the first 3 months of ART. CTX should be prescribed to all HIV-infected adults who initiate ART.

Effect of co-trimoxazole prophylaxis used for AIDS patients under anti-retroviral therapy

To analyze the situation of survival among AIDS patients under cotrimoxazole prophylaxis as initial anti-retroviral therapy (ART), in Henan province during 2007-2011. Information on AIDS patients receiving initial ART during 2007-2011 was collected from the Chinese HIV/AIDS Integrated Control System. Kaplan-Meier estimation was used to generate survival curves, and Cox proportional hazard regression model was used to determine associated factors of survival status. According to the previous CTX use before ART, the subjects were divided into 3 groups including who had never taken CTX, who had taken CTX and still taking now, who had taken CTX and not current taking. A total of 13 103 eligible AIDS patients were identified. 1 702 patients died within 6 years after the initiation of ART, with the mortality as 4.46/100 person year. Among the 455 patients who died within 3 months and 970 died within 12 months, the mortality rates were 14.15/100 person year and 7.78/100 person year, respectively. The Kaplan-Meier survival curves showed that the survival time and mortality of the patients who had taken CTX was longer AND lower than those patients who had never taken CTX when starting the ART program. Results from the log-rank test showed that the difference of two groups was statistically significant during 12 months after the ART(log-rank = 5.15, P = 0.02). After controlling for other variables, results from multivariable analysis of COX model showed that factors as age, gender, marital status, perion between confirmed diagnosis and receiving the ART, baseline CD4(+) T cells count, clinical stage, initial therapy schedule, date when starting the ART, number of symptoms at baseline, use of CTX before starting the ART and ART being skipped in the last seven days etc, were associated with the time of survival in patients after the initiation of ART. Patients who had been taking CTX at ART initiation were at lower risk of death (adjusted HR = 0.71, 95% CI:0.63-0.80; P = 0.00), compared to those who had never taken the CTX. The co-trimoxazole prophylaxis program was associated with the reduced mortality among AIDS patients who were on ART in Henan province, especially during the first year.

Balancing Individual Benefit Against Public Health Risk: The Impact of Cotrimoxazole Prophylaxis in HIV-infected Patients on Antimicrobial Resistance

Cotrimoxazole (trimethoprim-sulfamethoxazole) is routinely provided to individuals with AIDS in the United States and Europe for prevention of opportunistic infections, especially Pneumocystis jerovici pneumonia. In Africa, it has been shown to reduce human immunodeficiency virus (HIV)associated mortality and morbidity, 1,2 including reductions in the incidence of malaria, pneumonia, diarrhea, and hospital admissions. 2,3 The addition of insecticide-treated bednets (ITN) and antiretroviral therapy to cotrimoxazole prophylaxis has been demonstrated to have an even more profound impact on malaria rates than cotrimoxazole alone. 3 Despite the favorable outcomes associated with cotrimoxazole use in HIV-seropositive people, concerns have been raised that the widespread use of this drug for prophylaxis will contribute to antimicrobial resistance. 4 Because cotrimoxazole targets the same antifolate pathway enzymes, dihydrofolate reductase (DHFR) and dihydropteroate synthase (DHPS), as the antimalarial sulfadoxine-pyrimethamine (SP), its widespread use could theoretically contribute to increased rates of SP resistance. In this month’s issue of The American Journal of Tropical Medicine & Hygiene, Hamel and colleagues describe the effect of cotrimoxazole prophylaxis on antimicrobial resistance rates among HIV-positive and negative Kenyan adults using a prospective cohort methodology. 5 They selected Streptococcus pneumoniae and Escherichia coli as their sentinel bacterial pathogens. In addition, they assessed the effect of cotrimoxazole prophylaxis on Plasmodium falciparum malaria by screening isolates from parasitemic patients for mutations in the DHFR and DHPS genes. The study included three arms: HIV-negative individuals not receiving cotrimoxazole, HIVpositives with high CD4 counts ( 350 cells/L) who were not receiving cotrimoxazole, and HIV-positives with low CD4 counts who were taking cotrimoxazole. All patients were screened through nasopharyngeal and rectal swabs (for the pneumococcus and E. coli respectively) and by blood smears, at baseline, and then repeatedly out to six months of observation. Their analyses focused on within group changes in the rates of resistance to the sentinel pathogens, as opposed to looking at differences between the three groups in the cohort. This is an important point to emphasize, and is chiefly wherein some of our questions reside in interpreting their findings. Increased resistance to cotrimoxazole occurred within two weeks in the case of the pneumococcus and E. coli, a finding highly concordant with our own investigations of the effect of cotrimoxazole prophylaxis on pneumococcal resistance in infants exposed to HIV at birth. 6 However, the within group analysis found no effect of cotrimoxazole on the prevalence of P. falciparum isolates with resistance mutations. More specifically, among HIV-positive patients receiving cotrimoxazole, the proportion of those parasitemic who had triple or quintuple mutations present (these being the most important combinations in terms of resistance to DHFR or both DHFR and DHPS simultaneously, and hence of primary clinical relevance) was about the same when comparing those patients at baseline with six months later. The authors concluded that while cotrimoxazole use clearly accelerated antibiotic resistance, there was no evidence to suggest that the same problem was developing in P. falciparum. Moreover, parasitemia rates were reduced by almost 90% among those taking prophylaxis. Thus, this suggests a highly beneficial effect of prophylaxis, without evidence of a cost at the population level in terms of SP resistance. But was that really the case? Our reluctance to fully em

EFFECT OF COTRIMOXAZOLE PROPHYLAXIS TAKEN BY HUMAN IMMUNODEFICIENCY VIRUS (HIV)–INFECTED PERSONS ON THE SELECTION OF SULFADOXINE-PYRIMETHAMINE–RESISTANT MALARIA PARASITES AMONG HIV-UNINFECTED HOUSEHOLD MEMBERS

The purpose of this prospective cohort study was to assess the effect of cotrimoxazole prophylaxis taken by human immunodeficiency virus (HIV)-infected persons on the selection of sulfadoxine-pyrimethamine (SP)-resistant malaria parasites among HIV-uninfected household members. A total of 2,567 HIV-uninfected persons from 605 households were followed and blood specimens were collected each time an episode of Plasmodium falciparum malaria was diagnosed. Study participants were living in households where HIV-infected persons were either taking (exposed) or not taking (unexposed) cotrimoxazole prophylaxis. From all malaria episodes diagnosed, 50% of the specimens were randomly selected and tested for the presence of five key mutations known to mediate resistance to SP (dihydrofolate reductase [dhfr] Asn-108, Ile-51, and Arg-59, and dihydropteroate synthase [dhps] Gly-437 and Glu-540). Plasmodium falciparum isolates were recovered from 163 specimens in the exposed households and 113 specimens in the unexposed households, with similar proportions containing the dhfr triple mutant (37% versus 45%; P = 0.18), the dhps double mutant (64% versus 62%; P = 0.81), and the dhfr/dhps quintuple mutant (30% versus 32%; P = 0.74). The HIV-uninfected persons living with HIV-infected household members taking cotrimoxazole prophylaxis had a lower incidence of malaria (incidence rate ratio [IRR] = 0.64, 95% confidence interval [CI] = 0.50-0.83, P = 0.001) and fewer malaria episodes due to parasites containing the dhfr/dhps quintuple mutant (IRR = 0.61, 95% CI = 0.41-0.91, P = 0.014). Cotrimoxazole prophylaxis taken by HIV-infected persons did not select for SP-resistant malaria parasites among HIV-uninfected household members, and was associated with a lower overall incidence of SP-resistant malaria among household members.

Effect of co-trimoxazole prophylaxis, antiretroviral therapy, and insecticide-treated bednets on the frequency of malaria in HIV-1-infected adults in Uganda: a prospective cohort study

HIV-1 and malaria are common infections in Africa, and cause substantial morbidity and mortality. HIV infection has been associated with an increased incidence of malaria, and more severe disease. Our aim was to assess the effect of antiretroviral treatment (ART) on the frequency of clinical malaria in people with HIV, and to measure the additive effects of co-trimoxazole (trimethoprim and sulfamethoxazole) prophylaxis, ART, and insecticide-treated bednets. In 2001, we enrolled 466 HIV-infected individuals aged 18 years or older in Uganda in a prospective cohort study that provided co-trimoxazole prophylaxis to 399 participants after 5 months of no intervention. In 2003, we enrolled 138 survivors from the initial study, and 897 new participants from the same community, to take antiretroviral therapy (ART) in addition to co-trimoxazole prophylaxis. The ART was in most cases a combination of stavudine, lamivudine, and nevirapine or efavirenz. In 2004, we also gave participants insecticide-treated bednets. Households were visited weekly by study staff to record fever, illness, or death in the preceding 7 days. In cases of reported fever in the previous 2 days, we took blood to test for malaria parasites. We compared the frequency of clinical malaria, adjusting for CD4-cell count, age, sex, and season. 1035 individuals were given co-trimoxazole and ART (median age 38 years, 74% female, and median CD4-cell count 124 cells/microL); 985 of these, plus four new participants, received co-trimoxazole, ART, and bednets. There were 166 cases of clinical malaria in the study. Compared with a baseline malaria incidence of 50.8 episodes per 100 person-years, co-trimoxazole prophylaxis was associated with 9.0 episodes per 100 person-years (adjusted incidence rate ratio [IRR] 0.24, 95% CI 0.15-0.38); ART and co-trimoxazole with 3.5 episodes per 100 person-years (0.08, 0.04-0.17); and co-trimoxazole, ART, and bednets with 2.1 episodes per 100 person-years (0.05, 0.03-0.08). Malaria incidence was significantly lower during ART and co-trimoxazole than during co-trimoxazole alone (IRR 0.36 [95% CI 0.18-0.74], p=0.0056). A combination of co-trimoxazole, antiretroviral therapy, and insecticide-treated bednets substantially reduced the frequency of malaria in adults with HIV.

Co-trimoxazole is effective prophylaxis for people with HIV infection in Africa

QuestionWhat are the effects of co-trimoxazole prophylaxis on mortality, morbidity, viral load and CD4 cell count in people with HIV infection in Africa?Study designCross sectional time series.Main resultsDaily co-trimoxazole (800 mg trimethoprim, 160 mg sulphamethoxazole) prophylaxis significantly reduced mortality, morbidity, annual mean rate of increase of viral load and annual mean rate of decline of CD4 cell count from baseline (before co-trimoxazole prophylaxis; see Results tables 1 and 2).Authors’ conclusionsIn people with HIV infection, daily co-trimoxazole prophylaxis reduces mortality, morbidity, viral load increase and CD4 cell count decrease. It is a readily available, effective intervention for people with HIV infection in Africa.

Effect of co-trimoxazole prophylaxis on morbidity, mortality, CD4-cell count, and viral load in HIV infection in rural Uganda

Prophylaxis with co-trimoxazole (trimethoprim-sulphamethoxazole) is recommended for people with HIV infection or AIDS but is rarely used in Africa. We assessed the effect of such prophylaxis on morbidity, mortality, CD4-cell count, and viral load among people with HIV infection living in rural Uganda, an area with high rates of bacterial resistance to co-trimoxazole. Between April, 2001, and March, 2003, we enrolled, and followed up with weekly home visits, 509 individuals with HIV-1 infection and their 1522 HIV-negative household members. After 5 months of follow-up, HIV-positive participants were offered daily co-trimoxazole prophylaxis (800 mg trimethoprim, 160 mg sulphamethoxazole) and followed up for a further 1.5 years. We assessed rates of malaria, diarrhoea, hospital admission, and death. Co-trimoxazole was well tolerated with rare (<2% per person-year) adverse reactions. Even though rates of resistance in diarrhoeal pathogens were high (76%), co-trimoxazole prophylaxis was associated with a 46% reduction in mortality (hazard ratio 0.54 [95% CI 0.35-0.84], p=0.006) and lower rates of malaria (multivariate incidence rate ratio 0.28 [0.19-0.40], p<0.0001), diarrhoea (0.65 [0.53-0.81], p<0.0001), and hospital admission (0.69 [0.48-0.98], p=0.04). The annual rate of decline in CD4-cell count was less during prophylaxis than before (77 vs 203 cells per microL, p<0.0001), and the annual rate of increase in viral load was lower (0.08 vs 0.90 log(10) copies per mL, p=0.01). Daily co-trimoxazole prophylaxis was associated with reduced morbidity and mortality and had beneficial effects on CD4-cell count and viral load. Co-trimoxazole prophylaxis is a readily available, effective intervention for people with HIV infection in Africa.