More evidence to show that cotrimoxazole is still an essential medicine for people with HIV

Keith Alcorn
Published: 15 February 2012

Two must-read studies published this month reinforce the case for cotrimoxazole prophylaxis in people living with HIV in low and middle-income settings.

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 with HIV
  • 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 services
  • 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 these studies.

Barriers to providing cotrimoxazole

A 2007 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 countries.

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

Research carried out by the London School of Hygiene and Tropical Medicine in Malawi, Uganda and Zambia found that despite the international guidance, whether or not cotrimoxazole prophylaxis got offered within a national programme was dependent on local factors.

  • Policy makers and clinicians were more likely to be influenced by evidence from local studies.
  • If the evidence for cotrimoxazole was felt to be weak, it was not recommended, despite WHO 2000 guidelines.
  • Concerns about resistance impeded action; policy makers wanted more evidence.
  • Cotrimoxazole was seen to be less of a priority than ART access in some countries.
  • Cotrimoxazole 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 care workers

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 by:

  • Lack of national policy support for cotrimoxazole to be prescribed or dispensed by lower-level health care workers.

  • Insufficient training on the importance of cotrimoxazole prophylaxis.

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.

This content was checked for accuracy at the time it was written. It may have been superseded by more recent developments. NAM recommends checking whether this is the most current information when making decisions that may affect your health.
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