A review of the expanded use of co-trimoxazole in HIV-infected Africans

The HIV/AIDS epidemic affects large numbers of people in sub-Saharan Africa. Most are unaware of their HIV status. Despite two decades of scientific advance, the education of communities and the provision of antiretroviral medication to some, many still succumb to the virus. Can this situation be changed? Antiretroviral (ARV) drugs have been shown to be effective in both poor and rich communities.1,2 But for the majority, these agents remain unaffordable and difficult to access. After 2 years, the public-sector ARV rollout programme in South Africa remains under-subscribed and under-utilised.3 Diets, vitamins, micronutrients and herbal concoctions have been advocated.4 But none has provided the survival benefit, freedom from opportunistic disease, and completeness of recovery, of antiretroviral therapy. In recent years, research in developing cou ntries has suggested that the daily use of the sulfonamide combination antibiotic, co-trimoxazole (CTX, trimethoprim-sulfamethoxazole, TMP/SMX), enhances the survival of infected adults and children.6-8 Cotrimoxazole (CTX) use in patients with advanced HIV infection became widespread in the 1980s when efficacy against Pneumocystis jiroveci pneumonia (PJP) was demonstrated. In this context, prophylactic CTX was commenced at CD4 levels of 200 cells/μl or less or following an AIDS-defining condition including PJP itself, prolonged and unexplained fever and weight loss. It was discontinued once the CD4 count rose to and remained above 200 cells/μl for at least 6 months.9 But the landscape for prophylactic CTX use in Africa appears to be changing. Recent World Health Organization (WHO) Guidelines have recommended expanding CTX use to all HIV-infected persons – where CD4 levels are unknown – with symptomatic WHO stage 2, 3 or 4 disease and where CD4 counts are available, to all with counts below 350 cells/μl. All HIVinfected persons with TB - pulmonary and non-pulmonary – are to be placed on CTX prophylaxis irrespective of their CD4 cell count. A ‘universal option\' of ‘CTX to all\' is offered to those who live in regions of high HIV prevalence and inadequate health care support.10 When is CTX prophylaxis stopped? ‘The general view is to continue CTX prophylaxis in adults – in resource-poor settings – indefinitely.\' Southern African Journal of HIV Medicine Vol. 7 (3) 2006: pp. 28-3