As the government minister of public health for the African country of Luciarna, I recommend that co-trimoxazole should be used by primary care physicians as a prophylactic for patients co-infected with HIV and Tuberculosis in our nation. It is also probable that co-trimoxazole can be administered to patients with HIV and other microbial infections.
There is a substantial amount of evidence from scientific research studies conducted in African nations that support the utilisation of co-trimoxazole as a prophylactic in patients with HIV and Tuberculosis co-infection. The evidence supporting the introduction of co-trimoxazole to Lucinarna will be discussed below.
Prior to the introduction of co-trimoxazole it may be necessary to conduct some preliminary research studies to determine the effectiveness of the prophylactic within the population of Luciarna in terms of a potential genetic predisposition to resistance to co-trimoxazole. It may be necessary to trial the use of co-trimoxazole in patients co-infected with HIV and infections other than tuberculosis.
Depending on the outcome of this research, it may also be necessary to investigate alternative treatments for HIV and Tuberculosis co-infection that may include anti-retroviral and antibiotic or antimicrobial agents.
The prophylactic co-trimoxazole
Co-trimoxazole is an antimicrobial drug that is a combination of two antibacterial compounds, sulfamethoxazole and trimethoprim. Co-trimoxazole can be used to treat a wide variety of bacterial infections and has been used as a prophylactic in the treatment of HIV to reduce patient mortality when patients are also suffering from an additional microbial infection such as malaria (Laufer and Plowe, 2006, Malamba et al., 2006), pneumonia (Maynart et al., 2001) or tuberculosis (Zachariah et al., 2003), (Nunn et al., 2008).
As described by Nunn et al (2008), HIV and tuberculosis are the major causes of mortality in sub-Saharan Africa, which is why this report is focused on the co-infection of these two conditions.
Evidence supporting the introduction of co-trimoxazole to Luciarna
The study conducted by Nunn et al (2008) in Zambia comprised randomised clinical trials undertaken on HIV positive patients co-infected with pulmonary tuberculosis and yielded data showing that co-trimoxazole prophylaxis reduced mortality rates in patients compared to patients receiving a placebo (Nunn et al., 2008). The death rates observed in the study were 27.3 per 100 person years for co-trimoxazole treated patients versus 34.4 per 100 person years for the placebo group.
Nunn et al (2008) also showed that the hazard ratio for death (an estimate of survival for co-trimoxazole:placebo patients) was 0.79 using the Cox regression analysis (95% confidence interval 0.63 to 0.99), thus indicating that co-trimoxazole offers a benefit to patients in terms of survival.
Additional studies have also identified a reduction in mortality rates in groups treated with co-trimoxazole (Zachariah et al., 2002), (Zachariah et al., 2003), (Chintu et al., 2004), (Mermin et al., 2004), (Mwaungulu et al., 2004), (Grimwade et al., 2005), (Malamba et al., 2006). On the basis of this evidence, it is suggested that co-trimoxazole should be introduced to Luciarna as a prophylactic for patients with HIV and additional microbial infections.
Caveats to the proposal for the introduction of co-trimoxazole prophylaxis
The major and most notable caveat to the proposal of introducing co-trimoxazole as a prophylactic for HIV and Tuberculosis co-infection to the nation of Luciarna concerns the potential for genetic resistance to the drug within the national population. Although successful clinical trials have been conducted in several African nations including Zambia (Nunn et al., 2008), South Africa (Grimwade et al., 2005), Malawi (Zachariah et al., 2002), Senegal (Maynart et al., 2001), Uganda (Mermin et al., 2004) and Cote d’Ivoire (Anglaret et al., 1999), this is no guarantee that there will not be an higher incidence of innate resistance to co-trimoxazole within the population of Luciarna.
It is therefore suggested that a randomised clinical trial be performed in Luciarna similar to that performed by (Nunn et al., 2008) to identify the possibility of resistance within the population of our nation. Such a study should be based on the methods of Nunn et al (2008) and should include a similar sample size for patients given co-trimoxazole or placebo. If the outcome of this study in Luciarna shows similar results to those obtained from the study in Zambia, then it will be recommended that co-trimoxazole be introduced.
Other concerns regarding a pharmacological agent always include the safety issues, possible side effects and potential reactions with other drugs. Nunn et al (2008) showed that there were minimal effects on patients administered co-trimoxazole. The drug was described in that study as “generally safe and well-tolerated” and only 6 patients from a total of 416 patients given co-trimoxazole in the study of Nunn et al (2008) suffered side-effects from the drug that were severe enough for those patients to be withdrawn from the trial.
Higher incidences of mortality in HIV positive patients is largely due to bacterial co-infection, as reviewed by Nunn et al 2008, and is why co-trimoxazole has been shown to be so effective at reducing mortality in such patients. Therefore if the outcome of trials investigating co-trimoxazole treatment are not as successful as hoped, or show a high incidence of side-effects within the Luciarna population, alternative antibacterial, antimicrobial or antibiotic drugs could be trialled to investigate their effects on HIV and tuberculosis co-infection.
A clinical trial could also include HIV positive patients co-infected with other microbial infections (or without co-infection) in addition to tuberculosis co-infection, to investigate the mortality rates in other combinations of infections.
It is recommended, based on the data achieved from the study performed by Nunn et al (2008) and on the outcome of further preliminary studies, that co-trimoxazole should be administered in Luciarna by primary care physicians to HIV patients with tuberculosis. After further study, patients with HIV and other microbial infections may also be administered co-trimoxazole.