Voluntary Counseling, HIV Testing and Adjunctive Cotrimoxazole reduces Mortality in Tuberculosis Patients in Thyolo, Malawi

Category 2

The study was carried out in Thyolo District, in Southern Malawi, with a population of 650 000. The district has one government hospital, a mission hospital, and 18 health centres which are involved in TB control activities. The design was a 'before' and 'after' cohort study measuring end-of-treatment death rates in a group of TB patients offered an intervention package compared with historical controls who were not offered the intervention package in the previous year.

Goal of the Practice
  • Assess the feasibility of introducing voluntary CT within a TB control program setting
  • Determine if adjunctive cotrimoxazole is safe
  • Reduce mortality rates among TB-HIV co-infected patients offered cotrimoxazole
Core Components
  • A voluntary CT unit was established which included counselors and lab technicians. All TB patients registered at the health facilities in this district were referred to the voluntary CT unit, offered pre-test counseling, testing, and post-test counseling.
  • Patients who were HIV positive were offered cotrimoxazole in addition to their TB treatment regimen. Cotrimoxazole was offered twice daily for the duration of TB treatment and indefinitely afterwards. During the initial phase of treatment, cotrimoxazole was administered by directly observed therapy. During the continuation phase of treatment, patients self-administered the medications and were given a month-supply.
  • Compliance of self-administration of cotrimoxazole was assessed. Side-effects of cotrimoxazole were monitored.
  • All patients were followed to the end of treatment and treatment outcomes were verified by conducting household visits on a random sample of patients.
Noteworthy Results
  • Of the 1061 patients in the intervention group, 96% received pre-test counseling, 91% were HIV tested, and 88% received post-test counseling. Of those who received HIV testing, 77% were HIV infected.
  • 93% of the HIV positive patients and 65% of all the registered TB patients in the intervention group received cotrimoxazole approximately 4 days after registration.
  • Only 2% of patients on cotrimoxazole had a skin reaction.
  • A difference in survival rates between the intervention and control group became apparent after 4 months of TB treatment.
  • The overall end of treatment survival probability was higher for the intervention group (patients who received cotrimoxazole) than the control group (patients that did not receive cotrimoxazole).
Lessons Learned
  • High acceptability of voluntary HIV testing among TB patients
  • Voluntary CT feasible under routine conditions in a rural setting in Malawi
  • Cotrimoxazole is safe with minimal side-effects
  • the protective effect of the intervention was mainly seen in new patients, smear negative TB patients, and extra-pulmonary TB (this may possibly be explained by the fact that in other studies, cotrimoxazole provided the greatest benefit to patients who are most immune suppressed; patients who are TB smear-negative may be more immune suppressed than those who are TB smear-positive)
Focus Areas
Counseling and Testing
Implemented By
Medecins Sans Frontieres--Luxembourg
Participating Organization
  • Ministry of Health and Population
  • Malawi Infectious Disease Research Centre
  • Luxembourg Liverpool School of Tropical Medicine
  • UK National Tuberculosis Control Programme
  • Malawi
Clinic/Health facility
Target Population
  • Adults (over 18)
  • Adolescents (ages 13-17)
  • Children (ages 2-12)
1000 - 5000
Implementation Years
07/1999 - 06/2003