Co-trimoxazole prophylaxis in HIV — DTM&H MCQ

Correct answer: B — Co-trimoxazole preventive therapy

The correct answer is B, co-trimoxazole preventive therapy. This patient has a CD4 count of 120 cells/mm3, well below the threshold of 350 cells/mm3 (and certainly below 200) at which co-trimoxazole prophylaxis is indicated for adults with advanced HIV disease, as it reduces mortality and morbidity from bacterial infections, Pneumocystis jirovecii pneumonia, toxoplasmosis and malaria in high-burden settings such as Lesotho. She has no sulfonamide allergy, so there is no contraindication. Cryptococcal and TB screening have already been completed as part of the WHO advanced HIV disease package of care, and co-trimoxazole is the next standard step alongside ART initiation and adherence support. Why the other options are wrong: C. Azithromycin weekly for every patient: this is not part of routine WHO advanced HIV disease prophylaxis; azithromycin mass therapy is used in specific contexts such as trachoma control, not as universal HIV opportunistic infection prophylaxis. A. Fluconazole lifelong for every patient: fluconazole is used pre-emptively only when cryptococcal antigen screening is positive or for secondary prophylaxis after treated cryptococcal disease, not as blanket primary prophylaxis for every patient regardless of screening result. E. Ciprofloxacin after each meal: there is no WHO or clinical indication for routine fluoroquinolone prophylaxis in HIV care, and this dosing pattern has no evidence base. D. Praziquantel monthly: this treats schistosomiasis and is given as periodic mass drug administration in endemic areas, not as HIV-specific opportunistic infection prophylaxis tied to CD4 count. Key point: any adult with CD4 count 350 cells/mm3 or below (or WHO clinical stage 3 or 4), without sulfonamide allergy, should start co-trimoxazole preventive therapy alongside ART initiation.

Reference: WHO Consolidated Guidelines on HIV Prevention, Testing, Treatment, Service Delivery and Monitoring: Recommendations for a Public Health Approach, 2021 (co-trimoxazole prophylaxis for adults with CD4 <=350 cells/mm3 or WHO stage 3/4) - https://www.ncbi.nlm.nih.gov/books/NBK298965/