4Risk and benefits assessment

Recommendation: Routine co-trimoxazole preventive therapy (CPT) should be administered in all HIV-infected patients with active TB disease regardless of their CD4 count
Population: HIV-infected patients with active TB disease irrespective of their CD4 count
Intervention: Standard routine CPT administration
Quality of evidenceHighThe reduction in mortality is supported by the HIGH quality of the evidence.

The intervention shows decrease in morbidity and hospital admission (LOW quality of the evidence) with no significant increase in adverse events (MODERATE quality of the evidence)

Lack of specific evidence in HIV infected patients on ART
Benefits or desired effectsStrong (benefits outweigh risks)Reduction in mortality

Reduction in morbidity (bacterial infection, malaria, etc.) including among HIV-uninfected household members of people living with HIV receiving CPT (but not exclusively HIV-infected TB patients)
Risks or undesired effectsAdditional drug-related adverse events

Resistance rates to CPT among common pathogens may increase, although this was not the case on diarrhoeal pathogens in Uganda and on falciparum parasites in Mali (studies conducted among people living with HIV receiving ART – not exclusively HIV-infected TB patients – and their household members)
Values and preferencesStrongImprove quality of HIV care

Prevention of life-threatening opportunistic infections

Health-care workers would probably prefer standard policy regarding CPT irrespective of antituberculosis treatment
CostsStrongCPT is inexpensive and available

Unlikely to increase cost significantly

Avoiding additional hospitalization: potentially cost-saving
FeasibilityStrongRoutine CPT provision is part of HIV general care

Continuation of standard provision is very feasible

Downside is that CPT is a common antibiotic for people with and without HIV and it is often difficult to maintain regular supply for those in need.
Strength of recommendation

From: Annex 3, Co-trimoxazole preventive therapy (CPT) reduces morbidity and mortality in tuberculosis patients living with HIV – summary of findings and evaluation of the quality of the evidence

Cover of WHO Policy on Collaborative TB/HIV Activities
WHO Policy on Collaborative TB/HIV Activities: Guidelines for National Programmes and Other Stakeholders.
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