Two must-read studies published this month reinforce the
case for cotrimoxazole prophylaxis in people living with HIV in low and
A large meta-analysis of seven studies conducted by Amitabh
Suthar of the University
of North Carolina with
colleagues at the World Health Organization and the US Centers for Disease
Control found that cotrimoxazole prophylaxis reduced the death rate in people
taking antiretroviral therapy by around 60%. (Read
our report here).
An analysis of the cost-effectiveness of providing
cotrimoxazole prophylaxis to people taking antiretroviral therapy found that
cotrimoxazole would be highly cost-effective as an adjunct to ART even in the
poorest countries – which is hardly surprising, since the drug is very cheap
and widely available as an essential medicine. (Read the report on this study here).
What’s noteworthy about these studies is not so much the
headline findings as the fact that it’s still necessary to repeat the messages
about the effectiveness of cotrimoxazole. Cotrimoxazole prophylaxis against
Pneumocystis pneumonia was one of the first great breakthroughs in AIDS
treatment, and since the early 1990s the evidence of its value has just
continued to accumulate. Examples from the past ten years include the following observations:
Cotrimoxazole's impact on survival, serious illness and hospitalisation in people with HIV is largely due to its anti-bacterial and anti-protozoal properties. It protects against severe bacterial infections, malaria, toxoplasmosis and pnuemocystis carinii pneumonia. People starting antiretroviral treatment with low CD4 counts (especially below 100) may still be vulnerable to these infections prior to immune reconstitution and it is still not clear how long cotrimoxazole prophylaxis should continue after starting antiretroviral therapy.
WHO guidelines recommend that cotrimoxazole should be used
by adults with progressing HIV disease, and where HIV prevalence is high,
infectious diseases common and healthcare infrastructure is limited,
governments may want to consider simply giving cotrimoxazole to everyone with
HIV and to infants known or suspected of having been exposed to HIV, WHO
recommended in 2006.
It is also recommended for HIV-exposed infants, and for any
child with HIV with symptoms of HIV disease.
Indeed in 2004 WHO recommended that cotrimoxazole
prophylaxis for children should be part
of any national AIDS programme.
By 2008 Swaziland,
Botswana and Rwanda had achieved relatively high levels of
infant coverage, although other countries such as Nigeria,
Lesotho and Kenya were
providing cotrimoxazole to very few infants of HIV-positive mothers.
High levels of infant
coverage in Botswana, Rwanda and Swaziland appear to be associated
with national-level efforts to improve the follow-up and care of mothers with
HIV and their infants through:
- Specialised training for all health care workers
in maternal and newborn health in how to screen for and recognise infants
- Greater linkage of all programmes diagnosing mothers with HIV to promote
follow-up and testing of children
- Use of community-based organisations to follow
up mothers in the community to ensure continued engagement with newborn
- Integration of paediatric HIV activities into
district and regional health plans.
In Swaziland operations
research carried out by the Ministry of Health, Population Council, USAID and
the Elizabeth Glaser Pediatric AIDS Fund observed a 24% increase in
paediatric cotrimoxazole uptake after the implementation of a project to
improve access to quality postnatal care for all women.
So cotrimoxazole emerges as
just marker of how to do integrated HIV and maternal child health care well in
Barriers to providing
WHO survey of 41 high HIV burden countries representing 82% of the global
HIV burden showed that 38 had a national policy on adult cotrimoxazole
implementation, but only two-thirds had implemented the policy recommendations
on a national scale. In the WHO African region 11 out of 16 countries reported
full implementation of a national cotrimoxazole policy.
Respondents cited drug
stock-outs as the chief barrier to implementation in 19 of 27 responding
Other important reasons for
a lack of cotrimoxazole implementation for adults included:
- Insufficient health care worker awareness due to
lack of training and supervision; lack of monitoring requirement.
- Perceived low priority of cotrimoxazole
implementation due to the lack of a reporting requirement
out by the London School of Hygiene and Tropical Medicine in Malawi, Uganda
found that despite the international guidance, whether or not cotrimoxazole
prophylaxis got offered within a national programme was dependent on local
makers and clinicians were more likely to be influenced by evidence from
the evidence for cotrimoxazole was felt to be weak, it was not
recommended, despite WHO 2000 guidelines.
about resistance impeded action; policy makers wanted more evidence.
was seen to be less of a priority than ART access in some countries.
got onto the policy agenda in each country due to the influence of local
policy champions and their supporters among the NGO and medical
communities in each country who saw cotrimoxazole as a priority.
A review conducted
by AIDSTAR-One for USAID in 2010, which reviewed cotrimoxazole management
and availability in 15 countries found that where national programmes and
non-governmental organisations had worked together to assess demand, plan
procurement to meet the anticipated need and manage the supply chain,
cotrimoxazole was widely and consistently available. But, in countries where
partners were not well coordinated, availability was less reliable.
However, lest we think the problem of availability is solved,
the report also warned: “Continued commitment and coordination will be required
to sustain availability of cotrimoxazole given the ever-changing landscape of
donor priorities, grant awards and funding cycles.”
So, there remains a strong need for advocacy to maintain and expand cotrimoxazole availability, both as an aid to retention of newly-diganosed people in care until they are eligible for ART treatment, and as an adjunct to ART in those already receiving treatment.
Resources for health
Research for the Interagency
Task Team for Prevention of HIV Infection in Pregnant Women, Mothers and
Children has also shown that access to cotrimoxazole has been impeded
AIDSTAR has produced a
number of tools and job aids for health care workers to support making
cotrimoxazole available, increasing community awareness and demand.
WHO & UNICEF published
practical guidance on implementation and scale-up of cotrimoxazole
prophylaxis for infants and children in 2009.
Examples of successful practice
If you have been involved in the successful implementation of recent activities to improve cotrimoxazole uptake and coverage, we would like to hear from you with case studies for a forthcoming edition of HATIP. Please leave a comment below.