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8.1

Timing the initiation of co-trimoxazole in relation to initiating antiretroviral therapy

Since the most common initial side effect of co-trimoxazole and antiretroviral therapy (especially nevirapine and efavirenz) is rash, it is recommended to start co-trimoxazole prophylaxis first and to initiate antiretroviral therapy two weeks later if the individual is stable on co-trimoxazole and has no rash !-"#$%

8.2

&linical and laboratory monitoring of co-trimoxazole prophylaxis

The safety of co-trimoxazole in long-term use has been established% 'rug-related adverse events are uncommon and typically occur within the first few weeks of starting prophylaxis% &linical monitoring should be carried out regularly, ideally at a minimum of three monthly intervals, with individuals encouraged to report adverse symptoms as soon as they are noted !-"""$%

No specific laboratory monitoring is required among children, adolescents and adults receiving co-trimoxazole prophylaxis [A-III]

(articular interest should be paid to skin reactions and symptoms such as nausea, vomiting or )aundice% Skin reaction is the most common co-trimoxazole-related adverse event and is diagnosed clinically% !ttention should be paid to other medications the person is receiving with possible overlapping toxicity (such as efavirenz, nevirapine and isoniazid)% &o-trimoxazole and dapsone can induce haemolytic anaemia among people with glucose-*phosphate dehydrogenase deficiency% These drugs should not be prescribed to individuals, particularly children, with known or suspected glucose-*-phosphate dehydrogenase deficiency% +outine testing for glucose-*-phosphate dehydrogenase deficiency in resource-limited settings is not recommended% ,o specific laboratory monitoring is re-uired in individuals receiving co-trimoxazole prophylaxis% "f available, laboratory monitoring should be based on symptoms and signs (such as full blood counts if anaemia is suspected and liver function tests if hepatic dysfunction is suspected) !-"""$%

Six-monthly &'. count monitoring is recommended, if available, to guide when to initiate antiretroviral therapy% /nce antiretroviral therapy is initiated, monitoring should continue according to the standard of care for antiretroviral therapy management for the setting involved !-"""$%

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"n general, the impact of co-trimoxazole prophylaxis on antiretroviral therapy toxicity is minimal% !mong people on zidovudine-containing antiretroviral therapy regimens, the impact of overlapping blood toxicity with co-trimoxazole prophylaxis is not significant (except for people with advanced 8"# disease), and no additional laboratory monitoring is needed ;-"""$%

8.3

Treatment of bacterial and opportunistic infections among people taking co-trimoxazole prophylaxis

'espite the lack of data, it is recommended to use an alternative antibiotic (where available) for treating breakthrough bacterial infections among individuals living with 8"# receiving cotrimoxazole prophylaxis, while continuing co-trimoxazole !-"#$% :or toxoplasmosis and (&( infections, prophylaxis should be suspended and full active treatment initiated according to national guidelines% &o-trimoxazole prophylaxis should be recommenced after the treatment course !-"""$%

8.4

(reventing and treating malaria among people taking co-trimoxazole prophylaxis

!mong children, adults and adolescents receiving co-trimoxazole prophylaxis, breakthrough episodes of malaria should be treated, if possible, with antimalarial therapy that does not include sulfadoxine<pyrimethamine !-"""$% There is no evidence to date on the efficacy of sulfadoxine< pyrimethamine in treating episodes of malaria among people taking co-trimoxazole prophylaxis%

"n malaria-endemic areas, intermittent presumptive therapy for malaria is recommended for pregnant women% 1iven the benefits of co-trimoxazole in preventing and treating malaria, intermittent presumptive therapy is not recommended for pregnant women receiving cotrimoxazole prophylaxis !-"""$% Similarly, sulfadoxine<pyrimethamine=based intermittent presumptive therapy for malaria is not necessary for infants or children on co-trimoxazole prophylaxis !-"""$%

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