WHO Expert Consultation on Cotrimoxazole Prophylaxis in HIV Infection
WHO technical report series
Reference number: WHO/HIV/2006.01
Cotrimoxazole (CTX), also known as Sulfamethoxazole-Trimethoprim (SMX-TMP), is a broadspectrum antimicrobial agent that targets a variety of aerobic Gram-positive and Gram-negative organisms and protozoa. The drug is widely available in both syrup and solid formulations at low cost in most places, including resource-limited settings.
Provision of CTX as primary or secondary prophylaxis for prevention of Pneumocystis jiroveci pneumonia (PCP) (formerly Pneumocystis carinni pneumonia) and toxoplasmosis has been part of the standard care in the management of HIV-infected individuals in developed countries since the early 1990s. Though provisional WHO/UNAIDS guidelines for CTX have been in place since the year 2000, most countries have not implemented this intervention widely. Some of the concerns related to the slow implementation of CTX include the difference in etiology and burden of common opportunistic infections between developed and resource-poor countries, the potential for drug resistance, pill burden and the lack of guidelines for duration of therapy. There has also been concern over the limited evidence base on CTX prophylaxis. To date, more effort has gone toward scaling up the provision of antiretroviral therapy (ART), whose efficacy is undisputed, than toward implementing CTX prophylaxis.
Over the past few years, more data from resource-limited settings have become available on the feasibility and the positive impact of CTX prophylaxis on morbidity and mortality among adults and children infected with HIV. CTX has been shown to be effective in preventing bacterial infections and malaria, despite the existence of variable levels of resistance to CTX. In addition, with the scaling up of highly active antiretroviral therapy (HAART) in resource-poor settings, there is the possibility that immune reconstitution secondary to HAART may provide opportunities for discontinuing CTX.
This meeting was organized by WHO/HIV/HQ to review current developments in the use of CTX prophylaxis and to formulate comprehensive recommendations for CTX prophylaxis in adults and children in resource-limited settings.