Skip Navigation LinksHome > November 10, 2000 - Volume 14 - Issue 16 > Thresholds of CD4 cells for initiating trimethoprim-sulfamet...
AIDS:
Research Letter

Thresholds of CD4 cells for initiating trimethoprim-sulfamethoxazole prophylaxis in west Africa

Anglaret, Xavier; Toure, Siaka; Ouassa, Timothée; Dabis, François; N'Dri-Yoman, Thérèse

Free Access
Article Outline
Collapse Box

Author Information

Programme PAC-CI, Abidjan, Côte d'Ivoire.

Received: 20 July 2000; accepted: 21 August 2000.

PIn industrialized countries, guidelines for the prevention of opportunistic infections in patients with HIV infection have long been well defined and periodically updated [1]. In sub-Saharan Africa, where 70% of HIV-infected people are currently living, some of these international guidelines are not applicable, not only because of the limited resources of most African individuals, but also because of differences in the spectrum of HIV-related morbidity. Among these differences, the most striking are the importance of tuberculosis and bacterial diseases as the first and second causes of mortality, respectively, and the low prevalence of Pneumocystis carinii infection [2]. In Africa, the prophylactic interest in cotrimoxazole is mainly because of its activity against Plasmodium spp., Isospora belli and Toxoplasma gondii, and in its antibacterial activity, which may vary locally depending on the resistance rates of major bacterial pathogens such as non-typhi Salmonella and Streptococcus pneumonia[3,4].

Fig. 1 shows the most recent CD4 cell counts in the 133 episodes of invasive bacterial diseases, isosporiasis, toxoplasmosis and malaria, which occurred between 1996 and 1998 in adults enrolled in the ANRS 059 trial in Abidjan, Côte d'Ivoire [3]. In 35 (26%) of these episodes of severe diseases potentially preventable with cotrimoxazole, the most recent CD4 cell counts were higher than 200/mm3 and the most recent CD4 cell percentages higher than 15%, which is the threshold commonly used in industrialized countries for initiating prophylaxis against P. carinii pneumonia [1]. In addition, 93% of these episodes occurred in patients with CD4 cell counts lower than 500/mm3 or with CD4 cell percentages lower than 25%.

Fig. 1
Fig. 1
Image Tools

As previously reported, cotrimoxazole was shown in the ANRS 059 trial to decrease the occurrence of severe clinical events in patients included at WHO clinical stages 2 or 3, and, when stratifying by initial CD4 cell count, this protective effect was significant even in patients with CD4 cell counts of more than 200/mm3 at inclusion [3]. In Côte d'Ivoire, a national consensus statement recommended that cotrimoxazole prophylaxis should be used in HIV- infected adults at WHO clinical stages 2, 3, or 4, or with CD4 cell counts under 500/mm3[5]. One of our patients with a CD4 cell count of more than 200/mm3 was recently advised to stop cotrimoxazole, when consulting in a department of infectious diseases during a trip to Europe. We believe that this figure may help our colleagues from industrialized countries to have a better understanding of these recommendations.

Xavier Anglaret

Siaka Toure

Timothée Ouassa

François Dabis

Thérèse N'Dri-Yoman

Back to Top | Article Outline

References

1. US Public Health Service (USPHS) and Infectious Disease Society of America (IDSA). 1999 USPHS/IDSA guidelines for the prevention of opportunistic infections in persons infected with human immunodeficiency virus. MMWR 1999, 4 (RR-10): 1 –66.

2. Lucas SB, Hounnou A, Peacock C. et al. The mortality and pathology of HIV infection in a West African city. AIDS 1993, 7: 1569 –1579.

3. Anglaret X, Chene G, Attia A. et al. Early chemoprophylaxis with trimethoprim-sulphamethoxazole for HIV-1 infected adults in Abidjan, Côte d'Ivoire: a randomised trial. Lancet 1999, 353: 1462 –1468.

4. Wiktor S, Sassan-Morokro M, Grant A. et al. Efficacy of trimethoprim-sulphamethoxazole prophylaxis to decrease morbidity and mortality in HIV-1-infected patients with tuberculosis in Abidjan, Côte d'Ivoire: a randomised controlled trial. Lancet 1999, 353: 1469 –1475.

5. Société Ivoirienne de Pathologie Infectieuse et Tropicale. Première conférence de consensus en thérapeutique anti-infectieuse: cotrimoxazole en prophylaxie primaire des infections opportunistes chez les patients infectés par le VIH en Côte d'Ivoire. 19 February 1999; 10 pp.

© 2000 Lippincott Williams & Wilkins, Inc.

Login