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 Zambia HIV National Guidelines
 


Introduction  

HIV Counseling and Testing  

Sexually Transmitted Infections (STIs)  

General Principles of Antiretroviral Therapy for Chronic HIV Infection in Adults and Adolescents  

When to Start ARV Therapy for Chronic HIV Infection in Adults and Adolescents  

Initial Regimen for ARV Therapy  

Adherence  

Baseline evaluation and Monitoring  

Calculations: Ideal Body Weight, Body Mass Index and Creatinine Clearance  

ARV Therapy for Individuals with Tuberculosis Co-Infection  

Adverse Effects and Toxicity  

Immune Reconstitution Inflammatory Syndrome (IRIS)  

Changing or Stopping ART  

Treatment Failure  

Stopping ARV Therapy  

Post Exposure Prophylaxis  

Cotrimoxazole Prophylaxis  

WHO Staging in Adults and Adolescents  

Nutrition Care and Support  

Palliative Care in HIV and AIDS  

 Guide Editors
 Editor In Chief
    Joel E. Gallant, MD, MPH

Pharmacology Editor
    Paul Pham, PharmD, BCPS

Zambia Guideline Team
    Peter Mwaba MMed PhD FRCP
Alywn Mwinga MMed
Isaac Zulu MMed MPH
Velepie Mtonga MMed
Albert Mwango MBChB
and Jabbin Mulwanda MMed FCS
 

 

 

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Cotrimoxazole Prophylaxis

04-28-2008

RECOMMENDATIONS FOR INFANTS AND CHILDREN

  • Initiation of cotrimoxazole (CTX) prophylaxis: 
  • Begin CTX prophylaxis at 6 wks in all HIV-exposed infants (regardless of ARV history) and continue until HIV infection excluded
  • Children with presumed PCP or other symptomatic HIV disease should be treated and CTX prophylaxis continued until HIV infection definitively excluded
  • Infants with documented HIV infection:
  • -<1 yr: give CTX regardless of symptoms or CD4%
  • ->1 yr: give CTX if Stage 2, 3, or 4 HIV or if CD4% <25%
  • History of treated PCP: give secondary CTX prophylaxis with same regimen used for primary prophylaxis
  • Discontinuation of CTX prophylaxis: 
  • Discontinue when HIV infection definitively excluded (PCR or Ab negative) and at least 6 weeks after cessation of breast feeding
  • <5 years: Continue primary and secondary prophylaxis in HIV+ children regardless of immune recovery due to ART because of continued increased risk of bacterial infections.
  • >5 years: Can consider stopping CTX prophylaxis in accordance with adult/adolescent guidelines if on ART with good clinical and immune recovery, CD4 response, and secure supply of drugs.
  • Restart CTX if CD4% falls below the age-specific threshold for initiation or with new or recurrent WHO clinical Stage 2, 3, or 4 condition
  • Children with history of severe adverse reactions to CTX or other sulfa drugs: use dapsone 2 mg/kg following same guidelines apply
  • CTX may need to be discontinued for serious adverse events possibly due to CTX (extensive exfoliative rash, Stevens-Johnson syndrome, severe anemia or pancytopenia)
RECOMMENDATIONS FOR ADULTS AND ADOLESCENTS

  • Initiation of CTX Prophylaxis: 
  • Patients with WHO Stage 2, 3 or 4 disease, regardless of CD4 count.
  • CD4 <350, regardless of clinical stage. If WHO Stage 2 and no CD4 count, initiate CTX.
  • Dose: 960 mg daily (800 mg SMX + 160 mg TMP).
  • Can be safely continued or initiated during pregnancy regardless of stage or during breastfeeding.
  • Patients with history of treated PCP should be treated with secondary CTX prophylaxis with same regimen used for primary prophylaxis
  • When starting both CTX and ART: start CTX first; initiate ART 2 weeks later if no adverse effects from CTX
  • Discontinuation of Primary or Secondary CTX Prophylaxis: 
  • Stop CTX after immune recovery on ART: CD4 >350 for >6 months
  • Stop CTX for adverse drug reaction or drug toxicity such as jaundice, severe anaemia, pancytopenia or rash (extensive exfoliative dermatitis, Stevens-Johnson syndrome)
  • In absence of CD4 monitoring, no consensus; can consider discontinuation in patient on ART for >1 yr without stage 2, 3, 4 events, good adherence and secure ARV supply
  • Restart CTX if CD4 falls below threshold for initiation or with new or recurrent WHO clinical stage 2, 3, 4 condition
  • Monitor for potential side effects of CTX clinically every 3 months and manage accordingly (see Toxicity Grading Scale below); no specific lab monitoring required, but may be indicated depending on signs and symptoms. Most common side effects: bone marrow suppression, skin rash, hepatotoxicity
COTRIMOXAZOLE TOXICITY GRADING SCALE FOR ADULTS AND ADOLESCENTS Don't know why there's a line space between this title and the bulleted list.

  • Grade 1: Erythema. Continue CTX with careful and repeated observation and follow up. Provide symptomatic treatment, such as antihistamines, if available
  • Grade 2: Diffuse maculopapular rash, dry desquamation. Continue CTX with careful and repeated observation and follow up. Provide symptomatic treatment, such as antihistamines, if available
  • Grade 3: Vesiculation, mucosal ulceration. Discontinue CTX until adverse effect completely resolved (usually 2 weeks), then reintroduction or consider desensitization
  • Grade 4: Exfoliative dermatitis, Stevens-Johnson syndrome or erythema multiforme, moist desquamation. Permanently discontinue CTX.
TREATMENT OF OTHER INFECTIONS IN PATIENTS ON CTX PROPHYLAXIS

  • Bacterial infections: Use alternative antibiotic and continue CTX prophylaxis
  • PCP and toxoplasmosis: Stop CTX prophylaxis and treat infection, then restart prophylaxis after treatment course
  • Malaria: Treat with agent that does not include sulfadoxine-pyrimethamine, if possible
CTX DESENSITIZATION PROTOCOL (ADULTS AND ADOLESCENTS)

  • Day 1: 80 mg sulfamethoxazole (SMX) + 16 mg trimethoprim (TMP) (2 ml of oral suspension: 40 mg TMP + 200 mg SMX per 5 ml)
  • Day 2: 160 mg SMX + 32 mg TMP (4 ml of oral suspension)
  • Day 3: 240 mg SMX + 48 mg TMP (6 ml of oral suspension)
  • Day 4: 320 mg SMX+ 64 mg TMP (8 ml of oral suspension)
  • Day 5: 1 single-strength (480 mg) CTX tab (400 mg SMX + 80 mg TMP)
  • Day 6 and onwards: 2 single-strength CTX tabs or 1 double-strength tab (800 mg SMX + 160 mg TMP)

 
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