Prophylaxis of Opportunistic Infections. Part A: Module A2 Session 10. Objectives. Describe the prophylactic use of TMP/SMX and INH Describe the WHO recommendations for TMP/SMX and INH Understand when to prescribe prophylactic treatment, to whom and which regimen to use.
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Part A: Module A2
Resource Constrained Countries
Some of the prevention measures recommended in the U.S. are not too expensive and may provide opportunities to prevent OIs in developing countries
Indications for prophylaxis in resource constrained countries include use of the WHO clinical stage, and, where possible, CD4 count and viral load.
Avoid unpasteurized dairy products, raw or undercooked eggs, meat, poultry, or fish (sources of salmonella)
General Prevention Measures
UNAIDS recommends that Cotrimoxazole be part of a minimum package of care for adults and children living with HIV/AIDS in Africa.
Candidates for cotrimoxazole prophylaxis should be
recruited from all levels of health care facilities, AIDS
service organizations and nongovernmental
Initial prescription of prophylaxis should be prescribed
by trained health care personnel
Counseling should be provided
Prophylaxis should be offered to:
Recommended drug dosages
Adults: 1 DS tablet or 2 SS tablets daily
(1DS=SMX 800 mg+TMP 160 mg; 1SS=SMX 400 mg+TMP 80 mg)
Children: Cotrimoxazole syrup administered 1/day, daily
Recommended dose is TMP 10 mg/kg,
SMX 50 mg/kg
If syrup is unavailable, may use crushed tablets.
Health professional may switch from syrup to tablet to ensure
ongoing access to medication.
Duration of Treatment
Prophylaxis should be given life-long for
adults and children (>15 months)
For infants < 15 months:
Prophylaxis should continue until HIV infection has been
reasonably ruled out and there is no further risk of
For children > 15 months:
Prophylaxis should be administered if child has
Criteria for Stopping Treatment (adults and children)
Dapsone 50 mg 2 x daily or 100 mg /day
In patients with CD4<100 and positive toxoplasma antibodies, pyrimethamine 50 mg weekly + folinic acid 25 mg weekly should be added to regimen
Pentamidine aerosols 300mg/month are more difficult to implement, less effective (PCP), effect not entirely understood (toxoplasmosis)
In cases of non-life threatening adverse reactions, treatment should be stopped for 2 weeks, then the patient should be re-challenged with TMP/SMX in a gradually increasing dose
Follow upProphylaxis should be used where regular follow-up of patients is possible
In adults, follow up should be every month and then every 3 months
Children should be evaluated on monthly basis
In adults and children, monitoring for toxicity, clinical events, and compliance to treatment should be undertaken.
Monitoring of adults should also include hemoglobin and white blood counts every 6 months, where possible and when clinically indicated
Monitoring Each country should develop an implementation and monitoring plan for Cotrimoxazole prophylaxis
Concurrent monitoring for clinical effectiveness is important, especially in areas where widespread resistance is present; in addition to prophylaxis investigation into new interventions is necessary
Evaluation Program evaluation and clinical effectiveness indicators will be developed by a task force led by UNAIDS. Could include surveillance for:
Research Comparative studies to identify affordable alternative therapies
Further studies on dose and time of initiation
Willingness/ability to pay at the household level
Household income, savings, expenses impact
Cost TMP/SMX in the recommended dose of 1DS daily costs $US 60/year
Distribution Cotrimoxazole can be: Given through community clinics and home-care projects
Integrated into counseling activities, favoring the regular follow up of the PLH/A by a counselor at the same time as the cotrimoxazole prescription is renewed
Prerequisites The following should be in place before a PT service is considered:
Recommendations to Governments
1. Preventive therapy against tuberculosisshould be part of a package of care for people living with HIV/AIDS
2. Preventive therapy should only be used in settings where it is possible to exclude active TB cases and to ensure appropriate monitoring and follow-up
5. The priority for TB control programmes continues to be the detection and cure of infectious tuberculosis cases
6. National authorities must regulate the procurement and supply of tuberculosis drugs in order to prevent the development of drug resistance
Those who test positive for HIV should receive
People living with HIV are at risk ofdeveloping TB. They should be given health education and encouraged to seek early diagnosis and treatment of cough and other symptoms suggestive of TB.
2) Screening for active TB:
PT is inadequate treatment for active TB and could lead to the development of drug resistance if taken in such cases. Active TB should therefore be excluded before PT is started.
Do chest x-ray before considering PT.
Target those most PT is recommended for PPD-positive HIV- likely tobenefit infected individuals who do not have activeTB
In some settings it may not be feasible to perform PPD testing. Under these circumstances the following individuals may still be considered for preventive therapy if they are infected with HIV:
INH alone is the recommended drug regimen forpreventive therapy to those without active tuberculosis
Trials using combination treatment report higher
rates of adverse drug reaction
Isoniazid may be given as a daily, self-administered therapy for 6 months at a dose of 5 mg/kg to a maximum of 300 mg.
These individuals should be seen monthly and given 1-month supply of medication at each visit.
Compliance may be improved by giving anadditional 2-week emergency buffer supply to be used if the individual has to defer his or her monthly review.
Rifampicin-containing regimens are not recommended in order to eliminate the risk of promoting rifampicin resistance through inadequate screening procedures or by misuse of the tablets.
ContraindicationsPreventive therapy is contraindicated into PTpatients with active tuberculosis and in patients with active (chronic or acute) hepatitis
Active tuberculosis must be excluded before beginning preventive therapy
Isoniazid should be given with caution to individuals who consume alcohol daily
23-valent pneumococcal vaccine
Hepatitis B vaccination
Herpes Simplex: acyclovir 400 mg 2 x daily