Haematological recovery among people living with HIV after Cotrimoxazole prophylaxis discontinuation at Infectious Diseases Institute, An urban HIV Care Centre, in Uganda
Abstract
ABSTRACT
Introduction:
Co-trimoxazole (CTX) prophylaxis has been part of the minimum care package for HIV-infected patients in Africa since 2001. Both World Health Organization (WHO) and Uganda’s national HIV guidelines recommend discontinuation of CTX prophylaxis among patients who are stable on ART. CTX is associated with hematological complications including anemia and neutropenia among people living with HIV (PLWHIV). Resolution of cytopenias among PLWHIV is expected following discontinuation of CTX prophylaxis. However, there is limited data about hematological recovery after discontinuation of CTX among PLWHIV.
Objectives: To determine the proportion of PLWHIV previously on CTX prophylaxis with hematological complications including anemia and neutropenia who experience hematological recovery after discontinuation of CTX prophylaxis and factors associated with hematological recovery.
Methods: This was a quantitative retrospective cohort study in which electronic medical records of patients receiving HIV care at the Infectious Diseases Institute (IDI) in Uganda between August 2015 and March 2020 were retrieved and screened for eligible participants who had been on CTX and had hematological complications of anemia and/or neutropenia. Participants' hemoglobin (Hb) levels and neutrophil counts done after discontinuation of CTX were assessed for improvement or resolution of anemia and neutropenia. Hemoglobin recovery was defined as Hb level ≥11g/dl (females), ≥12g/dl (males), or an increase in Hb by >2g/dl in absolute values, and neutrophil count recovery was defined as neutrophil count ≥1×10³/µl or increase in neutrophil counts by ≥0.5×103/µl after discontinuation of CTX prophylaxis. Multivariable logistic regression analysis was performed to evaluate factors associated with hematological recovery after discontinuation of CTX prophylaxis.
Results: A total of 263 participants, with a median age of 46 years (interquartile range, IQR: 39.0-52.0 years), were enrolled in this study. The majority of the participants were females (n=179, 68.1%). The median duration of CTX prophylaxis was 3.5 years (IQR: 1.7-3.8 years). The proportions of participants who experienced hematological recovery after discontinuation of CTX prophylaxis were 42.9% (79/184) for Hb and 81.1% (73/90) for neutrophil counts. Males were less likely to experience neutrophil recovery (AOR=0.28, CI:0.10-0.92, p= 0.037) and overweight participants were less likely to experience Hb recovery (AOR=0.33, CI:0.12-0.93, p=0.035). No association was found between hematological recovery and age, baseline CD4 counts, duration on CTX, AZT-based ART regimens, TB drugs, and WHO HIV stages (p-value>0.05).
Conclusion: The proportion of hematological recovery among PLWHIV after discontinuation of CTX prophylaxis was found to be relatively higher for neutrophil counts (about 4 in 5 participants) than for hemoglobin levels (about 2 in 5 participants). Males were less likely to recover from neutropenia and overweight participants were less likely to recover from anemia after discontinuation of CTX prophylaxis.
Recommendation: These findings support the discontinuation of CTX prophylaxis among HIV-infected patients with persistent cytopenias including anemia and neutropenia.