Cotrimoxazole Discontinuation in Malaria Endemic Areas Increases Rate of Malaria

 

Dr. Christina Polyak MD MPH Acting Instructor with the University of Washington Clinical research physician at the U.S. Military HIV Research Program Walter Reed Army Institute of Research at WRAIR Bethesda, MD 20817 Medical Research: What is the background for this study? What are the main findings? Dr. Polyak: Today, 35 million people are infected with HIV, the virus that causes AIDS. Cotrimoxazole (CTX) is low-cost and widely utilized broad spectrum antibiotic used to prevent opportunistic infections in patients with HIV. CTX prophylaxis is recommended by the World Health Organization (WHO) for HIV infected adults in settings with high infectious disease prevalence. In these settings, the threshold for CTX discontinuation is undefined. We designed a study to determine whether CTX discontinuation was non-inferior to continued CTX-prophylaxis in decreasing morbidity in adults with evidence of immune reconstitution (CD4 >350 and 18 months on ART). Our findings show that combined morbidity/mortality was significantly higher in the CTX discontinuation arm (RR=2.27, 95% CI 1.52-3.38;p<0.001), driven by malaria morbidity. This suggests that CTX discontinuation among ART-treated, immune-reconstituted adults in malaria-endemic regions resulted in increased incidence of malaria but not pneumonia or diarrhea. These data helped inform and support the 2014 WHO CTX guidelines. Medical Research: What should clinicians and patients take away from your report? Dr. Polyak: CTX discontinuation among ART-treated adults in a region with endemic malaria resulted in increased incidence of clinical malaria but not pneumonia or diarrhea. The implications are broad and our results suggest that CTX prophylaxis should continue in regions with endemic malaria. Medical Research: What recommendations do you have for future research as a result of this study? Dr. Polyak: Understanding the burden of malaria, pneumonia and diarrhea in the HIV-uninfected community would be prudent to compare background rates of disease. Citation: Cotrimoxazole Prophylaxis Discontinuation among Antiretroviral-Treated HIV-1-Infected Adults in Kenya: A Randomized Non-inferiority Trial Christina S. Polyak ,Krista Yuhas, Benson Singa, Monica Khaemba, Judd Walson, Barbra A. Richardson,Grace John-Stewart Published: January 5, 2016 DOI: 10.1371/journal.pmed.1001934

Dr. Christina Polyak

MedicalResearch.com Interview with:
Dr. Christina Polyak MD MPH
Acting Instructor with the University of Washington
Clinical research physician at the U.S. Military HIV Research Program
Walter Reed Army Institute of Research at WRAIR
Bethesda, MD  20817

Medical Research: What is the background for this study? What are the main findings?

Dr. Polyak:    Today, 35 million people are infected with HIV, the virus that causes AIDS.   (CTX)  is low-cost and widely utilized broad spectrum antibiotic used to prevent opportunistic infections in patients with HIV.  CTX prophylaxis is recommended by the World Health Organization (WHO) for HIV infected adults in settings with high infectious disease prevalence.   In these settings, the threshold for CTX discontinuation is undefined.  We designed a study to determine whether CTX discontinuation was non-inferior to continued CTX-prophylaxis in decreasing morbidity in adults with evidence of immune reconstitution (CD4 >350 and 18 months on ART).  Our findings show that combined morbidity/mortality was significantly higher in the CTX discontinuation arm (RR=2.27, 95% CI 1.52-3.38;p<0.001), driven by malaria morbidity.   This suggests that CTX discontinuation among ART-treated, immune-reconstituted adults in malaria-endemic regions resulted in increased incidence of malaria but not pneumonia or diarrhea.  These data helped inform and support the 2014 WHO CTX guidelines.

Medical Research: What should clinicians and patients take away from your report?

Dr. Polyak:     CTX discontinuation among ART-treated adults in a region with endemic malaria resulted in increased incidence of clinical malaria but not pneumonia or diarrhea. The implications are broad and our results suggest that CTX prophylaxis should continue in regions with endemic malaria.

Medical Research: What recommendations do you have for future research as a result of this study?

Dr. Polyak:     Understanding the burden of malaria, pneumonia and diarrhea in the HIV-uninfected community would be prudent to compare background rates of disease.

Citation:

Cotrimoxazole Prophylaxis Discontinuation among Antiretroviral-Treated HIV-1-Infected Adults in Kenya: A Randomized Non-inferiority Trial

Christina S. Polyak ,Krista Yuhas, Benson Singa, Monica Khaemba, Judd Walson, Barbra A. Richardson,Grace John-Stewart 

Published: January 5, 2016 DOI: 10.1371/journal.pmed.1001934

Dr. Christina Polyak MD MPH (2016). Cotrimoxazole Discontinuation in Malaria Endemic Areas Increases Rate of Malaria MedicalResearch.com

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