Effect of cotrimoxazole on mortality in HIV-infected adults on antiretroviral therapy : a systematic review and meta-analysis

Suthar, Amitabh B.; Granich, Reuben; Mermin, Jonathan; Van Rie, Annelies

doi:10.2471/BLT.11.093260

Title

Effect of cotrimoxazole on mortality in HIV-infected adults on antiretroviral therapy : a systematic review and meta-analysis

Author

Suthar, Amitabh B.

Granich, Reuben

Mermin, Jonathan

Van Rie, Annelies

Abstract

Objective To determine whether cotrimoxazole reduces mortality in adults receiving antiretroviral therapy (ART) for human immunodeficiency virus (HIV) infection in low- and middle-income countries through a systematic review and meta-analysis. Methods PubMed and Embase were searched for randomized controlled trials and prospective and retrospective cohort studies that compared mortality or morbidity in HIV-infected individuals aged >= 13 years on cotrimoxazole and ART and on ART alone. The Newcastle-Ottawa Quality Assessment Scale was used to assess selection, confounding and measurement bias. Publication bias was assessed using Egger's and Begg's tests. Sensitivity analysis was performed because the I-squared statistic indicated substantial heterogeneity in study results, A random-effects model was used for meta-analysis. Findings Nine studies were included. Begg and Egger P-values for the seven that reported the effect of cotrimoxazole on mortality were 0.29 and 0.49, respectively, suggesting no publication bias. The I-squared statistic was 93.2%, indicating high heterogeneity in study results. The sensitivity analysis showed that neither the follow-up duration nor the percentage of individuals with World Health Organization stage 3 or 4 HIV disease at baseline explained the heterogeneity. The summary estimate of the effect of cotrimoxazole on the incidence rate of death was 0.42 (95% confidence interval: 0.29-0.61). Since most studies followed participants for less than 1 year, it was not possible to determine whether cotrimoxazole can be stopped safely after ART-induced immune reconstitution. Conclusion Cotrimoxazole significantly increased survival in HIV-infected adults on ART. Further research is needed to determine the optimum duration of cotrimoxazole treatment in these patients.

Language

English

Source (journal)

Bulletin of the World Health Organization. - Genève

Publication

Geneva 27 : World health organization , 2012

ISSN

0042-9686

DOI

10.2471/BLT.11.093260

Volume/pages

90 :2 (2012) , p. 128-138