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Guidance on Cotrimoxazole Prophylactic Therapy for

HIV Exposed/Infected Children

HAIVNHarvard Medical School AIDS

Initiative in Vietnam

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By the end of this session, participants should be able to: Explain indications of Cotrimoxazole

Prophylactic Therapy (CPT) for HIV-exposed and HIV-infected children

Describe clinical and testing follow up while taking CTX Prophylactic Therapy

Can explain when stop taking CTX Prophylactic Therapy

Learning Objectives

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Introduction

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Anti-retrovirus treatment could prevent OIs

Some medications (mainly CTX) have been proved that they could prevent OIs

Counseling people who provide care for infected children: • Food hygiene • Good nutrition• Regular check up

OI Prophylactic Therapies

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Primary prophylaxis: Giving medication

to prevent an OI from occurring in the first place

Secondary prophylaxis: Giving medication

after an OI is treated to prevent it from recurring

Also known as maintenance therapy

Two Types of OI Prophylaxis

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Cotrimoxazole (CTX): Combination of sulfamethoxazole

and trimethoprim Broad-spectrum antibiotics for gram

positive and negative bacteria, fungi and protozoa

Cotrimoxazole prophylaxis: Overview (1)

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CTX prophylaxis: A part of a standardized Care and

Treatment Package for HIV/AIDS patients

High effective, simple, and economical intervention

Need to be maintained until having evidence of immunological recovery.

Cotrimoxazole prophylaxis: Overview (2)

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Prevents:• PCP (Pneumocystis jiroveci pneumonia)• Cerebral toxoplasmosis

Reduces the occurrence of:• Pneumonia due to streptococcus

pneumoniae, Nocardia, Haemophilus Influenzae, S. aureus, gram-negative bacilli

• Diarrheas due to Salmonella, Isospoiaris and protozoa

• Malaria

Cotrimoxazole prophylaxis: Overview (3)

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PCP is the most common OI in infants and young children • Mortality associated with PCP in infants

is as high as 40% despite treatment CPT is highly effective at preventing

PCP • CPT has been shown to reduce mortality

in infants and children

CTX prophylaxis for PCP

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High Rate of PCP in Infants Age 2-8 Months

Age in Months

Nu

mb

er o

f C

ases

0

0

50

100

150

200

250

300

350

400

450

2 4 6 8 10 12 14 16 18 20 22 24

Other AIDS-defining conditions

Pneumocystis carinii pneumonia

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Indications and Dosefor Cotrimoxazole Prophylaxis

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Prevent OIs: PCP Cerebral toxoplasmosis Some diarrheas Pneumonia due to bacterium

Objective of CTX prophylaxis

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All HIV-exposed infants/children:

Starting at 4–6 weeks of age and Continued until HIV infection is

excluded

Indications for Primary Cotrimoxazole Prophylaxis

Hướng dẫn Quốc gia về Chẩn đoán và Điều trị HIV/AIDS. Bộ Y tế, Việt Nam, 2011.

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HIV-confirmed children

< 24 months

old•All children regardless of symptoms or CD4 count

24-60 months

old

•Clinical stages 2, 3, 4 regardless of CD4 count or

•CD4 ≤ 25% or CD4 ≤ 750 cells/ml regardless of

clinical stage

≥ 5years old

•Clinical stages 1, 2 with CD4 ≤ 350 cells/ml

•Clinical stages 2, 3, and 4 if CD4 unavailable or

•Clinical stages 3, 4 regardless of CD4 count

Indications for Primary Cotrimoxazole Prophylaxis (2)

National Guidelines for the Diagnosis and Treatment of HIV/AIDS. Ministry of Health, Vietnam. 2011.

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Exposed/infected children who acquired: PCP Cerebral toxoplasmosis

Indications for Secondary Cotrimoxazole Prophylaxis

Hướng dẫn Quốc gia về Chẩn đoán và Điều trị HIV/AIDS. Bộ Y tế, Việt Nam, 2011.

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Thành phần

Trimethoprim (TMP) andSulfamethoxazole (SMX)

Dosing 5 mg TMP/kg/day once a day

Formulations

Liquid 8mg TMP/40mg SMXper 1ml

Tablet

80mg TMP/400mg SMX(480mg tablet)

Or

160mg TMP/800mg SMX(960mg tablet)

CTX Prophylaxis: dosing

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Nausea, vomiting Rash can occur during first 1-2 weeks Severe side effects:

• Anemia• Granulocytopenia• Hypersensitivity reaction• Hepatotoxicity

Cotrimoxazole Side Effects (1)

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Need to counsel for care givers and children:• Side effects• How to manage• Check up immediately when suspected

signs of severe side effect occur Do complete blood count, liver

enzymes measuring when anemia or hepatotoxicity is suspected

Cotrimoxazole Side Effects (2)

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Divided into 4 groups Topics of discussion:

• Group 1: manifestations/symptoms of rash at grade 1 and how to manage

• Group 2: manifestations/symptoms of rash at grade 2 and how to manage

• Group 3: manifestations/symptoms of rash at grade 3 and how to manage

• Group 4: manifestations/symptoms of rash at grade 4 and how to manage

Time: 10 minutes

Group Discussion

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Grade Clinical description Management

Grade 1(mild)

Erythema -Continue CPT with careful follow up.-Provide symptomatic treatment and anti-histamine

Grade 2(moderate)

Diffuse maculopapular rash, dry desquamation

Grade 3(severe)

Bulla, mucosal ulceration - Hospitalization with supportive treatment- CTX should be permanently discontinued

Grade 4(very

severe)

Exfoliative dermatitis, Steven Johnson syndrome or erythema multiforms, moist desquamation

Rash due to CTX and management

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There are no adequate data on CTX desensitization in children

Other medications need to be noticed and may be overlapping drug toxicity: • EFV • NVP • Isoniazid…

Rash due to CTX and management

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Indication: allergy to CTX Dose:

• 2mg/kg/day, once a day or• 4mg/kg/time, once a week

Note: • Less effect than CTX in terms of PCP

prevention• Can not prevent Toxoplasma

Alternative Therapy: Dapson

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Indication of discontinuing CPT

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Discontinuing CPT for HIV-exposed Children

Stop CTX prophylaxis when HIV infection has been definitively excluded

Infants <18 months Children >18 months

Confirmed negative HIV virological test and antibody

test

6 weeks after complete cessation of breastfeeding

Confirmed negative HIV antibody test

6 weeks after complete cessation of breastfeeding

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Discontinuing CPT forHIV-infected Children (While on ARV)

National Guidelines for the Diagnosis and Treatment of HIV/AIDS. Ministry of Health, Vietnam. 2009.

0-24 months old Do not discontinue

24-60 months old

Discontinue when:

CD4 count > 25% for at least 6 months

5 years old

Discontinue when:

CD4 count > 200 for at least 6 months

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Case Study

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CPT is highly effective for prevention of PCP in infants and children

All HIV-exposed infants should receive CPT starting at 4–6 weeks of age

Follow up closely CTX side effects and manage them timely

Indication of discontinuing CPT:• Exposed infants: HIV infection has been

definitively excluded • Infected infants/children: after ARV treatment and

CD4 higher the threshold as MOH required for each age group for 6 months continuously.

Key Points

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Thank you!

Questions?