Table 4.

Summary of recommendations for discontinuing primary cotrimoxazole among infants and children

Target population
HIV-exposed children is excluded !"-I#

Recommendations
iscontinue co-trimoxazole prophylaxis after HIV infection

$aintain on co-trimoxazole prophylaxis until age fi%e years irrespecti%e of clinical and immune response !"-IV# Infants and children li%ing 'ith HIV &hildren older than fi%e years can be reassessed and consideration can be gi%en to discontinuing co-trimoxazole prophylaxis in accordance 'ith the recommendations for adults and adolescents !&-IV#

Severe adverse reactions to co-trimoxazole in children are uncommon, In the CHAP study (7), 5 ! children "ere randomized to co-trimoxazole or #lace$o% &o child on cotrimoxazole develo#ed rash%

(.4.)

iscontinuation for co-trimoxazole ad%erse reactions

&o-trimoxazole prophylaxis may need to be discontinued in the e%ent of an ad%erse drug reaction. "lthough se%ere reactions to co-trimoxazole are uncommon* these may include extensi%e exfoliati%e rash* Ste%ens-+ohnson syndrome or se%ere anaemia or pancytopaenia. There are insufficient data on co-trimoxazole desensitization ,rechallenge follo'ing an ad%erse reaction to co-trimoxazole commencing 'ith lo' doses of co-trimoxazole and gradual dose escalation- among children to ma.e any recommendations on its use in resource-limited settings.

/%eryone starting co-trimoxazole and their guardians and caregi%ers should be pro%ided 'ith %erbal or 'ritten information on potential ad%erse effects and ad%ised to stop the drug and report to their nearest health facility if co-trimoxazole-related ad%erse e%ents are suspected ,Table 0-.

1 0

6.5

iscontinuation of secondary co-trimoxazole prophylaxis

The safety of discontinuing secondary co-trimoxazole prophylaxis among children li%ing 'ith HIV has had limited assessment and has been studied only in high2income countries (' ). The general recommendation is that secondary co-trimoxazole prophylaxis should not be discontinued* irrespecti%e of clinical and immune response to antiretro%iral therapy ((5) !3-III#. 3ased on e%idence that secondary co-trimoxazole prophylaxis can be safely stopped among adults and adolescents guided by immune reco%ery in response to antiretro%iral therapy assessed using & 4 cell count ( ) 7)* discontinuation of secondary co-trimoxazole prophylaxis may be considered among children older than fi%e years 'ith e%idence of immune reco%ery in response to antiretro%iral therapy in accordance 'ith the recommendation for discontinuation of primary prophylaxis !&-IV#.

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-$ H;9ECC;D:7J?EDIEDJ>;KI;E<FH?C7HO9E#JH?CEN7PEB; FHEF>OB7N?I7CED=7:KBJI7D:7:EB;I9;DJI

7.1

"dults and adolescents among 'hom co-trimoxazole prophylaxis is contraindicated

"dults and adolescents 'ith a history of se%ere ad%erse reaction ,grade 4? see Table 0- to cotrimoxazole or other sulfa drugs should not be prescribed co-trimoxazole prophylaxis. In situations in 'hich co-trimoxazole cannot be continued or should not be initiated* dapsone 1@@ mg per day* if a%ailable* can be used as an alternati%e. apsone is less effecti%e than cotrimoxazole in pre%enting <&< and also lac.s the broad antimicrobial acti%ity of co-trimoxazole. It is therefore desirable to attempt desensitization ,section 0.4.)- to co-trimoxazole* if feasible in the clinical setting* among indi%iduals 'ith a pre%ious non-se%ere reaction* before substituting dapsone !"-IV#. Ho'e%er* co-trimoxazole desensitization should not be attempted among indi%iduals 'ith a pre%ious se%ere ,grade 4- reaction to co-trimoxazole or other sulfa-containing drugs.

7.2

Initiation of primary co-trimoxazole prophylaxis among adults and adolescents

These recommendations include a degree of flexibility to enable decisions on the most appropriate threshold of & 4 count or clinical disease stage for initiation of co-trimoxazole prophylaxis to be made at the country le%el or e%en the local le%el* ta.ing into account %ariation in the burden of HIV* disease spectrum and the capacity and infrastructure of health systems. In settings in 'hich co-trimoxazole prophylaxis is initiated based on AH9 clinical staging criteria only* co-trimoxazole prophylaxis is recommended for all symptomatic people 'ith mild* ad%anced or se%ere HIV disease ,AH9 clinical stages B* ) or 4- !"-I#. Ahere & 4 cell testing is a%ailable* co-trimoxazole prophylaxis is recommended for e%eryone 'ith a & 4 cell count C)D@ per mm )* particularly in resource-limited settings 'here bacterial infections and malaria are pre%alent among people li%ing 'ith HIV !"-III#. Some countries may choose to adopt a & 4 threshold of B@@ cells per mm ) belo' 'hich cotrimoxazole prophylaxis is recommended. This option is especially recommended if the main targets for co-trimoxazole prophylaxis are <&< and toxoplasmosis !"-I#. Ho'e%er* bacterial infections are pre%alent in indi%iduals li%ing 'ith HIV in all settings* 'hich supports the use of the )D@ cells per mm) threshold. <eople 'ith AH9 clinical stage ) or 4 HIV disease ,including people 'ith pulmonary as 'ell as extrapulmonary T3- should* ho'e%er* still initiate co-trimoxazole prophylaxis irrespecti%e of the & 4 cell count !"-I#.

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