Dr. D. M. Gibb, at the Medical Research Council Clinical Trials Unit in London, along with members of the Children with HIV Antibiotic Prophylaxis (CHAP) trial team, enrolled children in Zambia ages 12 months to 15 years. Subjects were randomly assigned to co-trimoxazole or placebo. 74 (28 per cent) of those in the co-trimoxazole group and 112 (42 per cent) in the placebo group died. The authors noted that duration of treatment, age, and baseline CD4 counts did not affect these results.

Dr. Gibb's team pointed out that bacterial resistance to co-trimoxazole was common (estimated 60 per cent to 80 per cent).

Prophylactic dosing with cotrimoxazole for HIV infected children with any sign or symptoms suggestive of HIV is a key intervention that should be offered as part of a basic package of care to reduce morbidity and mortality.

Cotrimoxazole prophylaxis is also a crucial potentially life saving intervention that should be given to all HIV exposed children born to HIV-infected mothers, in settings where HIV infection status cannot be reliably confirmed in the first 18 months of life.

Cotrimoxazole is a widely available antibiotic that is available in syrup and solid formulations at low-cost in most settings, including resource limited settings. It is highly effective for the treatment and prevention of Pneumocystis pneumonia. In HIV infected children it also offers protection against other infections, this remains important even with increasing access to costly anti retro viral (ARV) treatment.

So greater advocacy for the use of cotrimoxazole prophylaxis in children is urgently required.

Who should get cotrimoxazole
* All HIV exposed children (children born to HIV infected mothers) from 4-6 weeks of age
* Any child identified as HIV-infected with any clinical signs or symptoms suggestive of HIV, regardless of age or CD4 count.

How long should cotrimoxazole be given
Cotrimoxazole is required to be taken as follows:
* HIV exposed children until HIV infection has been definitively ruled out and the mother is no longer breastfeeding
*HIV infected children - indefinitely where ARV treatment is not yet available.
*Where ARV treatment is being given- cotrimoxazole can be stopped only once clinical or immunological indicators confirm restoration of the immune system for 6 months or more.

Under what circumstances should cotrimoxazole be discontinued:
*Occurrence of severe cutaneous reactions such as Stevens Johnson syndrome, renal and/or hepatic insufficiency or severe hematological toxicity.
*In an HIV exposed child only once HIV infection has confidently been excluded;

For a non-breastfeeding child <18 months of age this is by negative DNA or RNA virological HIV testing

For a breastfed HIV exposed child < 18 months negative virological testing is only reliable if conducted 6 weeks after cessation of breastfeeding,

For a breastfed HIV-exposed child >18 months - negative HIV antibody testing 3 months after stopping breastfeeding

In an HIV-infected child:

If the child is on ARV therapy, cotrimoxazole can be stopped only when evidence of immune restoration has occurred. This can be assumed where the child is over 18 months of age and Cd4% >15 at two measurements, at least 3 to 6 months apart. If a CD4 count is not available, cotrimoxazole should not be stopped before a full 6 months of successful adherence to ARV therapy, and then only when clinical evidence of immune restoration is present. Continuing cotrimoxazole may continue to provide benefit even once child has clinically improved.

If ARV therapy is not available it should not be discontinued

What doses of cotrimoxazole should be used?
* Syrup use is recommended in very young children up to 10-12 kg
* Recommended dosages of 6-8 mg/kg once daily should be used.
* Once tablets can be taken, half of a standard adult tablet crushed may be used for children up to 10kg, one whole tablet for 10-25kg, two single strength or one double strength for over 25kg.
*Use weight band dosages rather than body surface area doses
*If the child is allergic to cotrimoxazole, dapsone is the best alternative

Other operational issues Drug supplies --
*Cotrimoxazole should be prescribed by the health care providers responsible for HIV care of the child.
*Providers should ensure regular sustained supply of high quality cotrimoxazole, and ensure the child has enough supply until after the next scheduled appointment for regular monitoring or ARV related care. This should ensure doses are not missed.
*Governments need to ensure an uninterrupted drug supply for both treatment and prophylaxis is available. This requires accurately estimating programme needs and extra budgetary allocation.
*Private sectors including industry and other medical insurance plans, should be encouraged to provide prophylaxis to families and include provision for children

Patient information
Patients need to be clear that while cotrimoxazole does not cure HIV, regular dosing is essential for protection of children from infections that are more common or more likely to occur in HIV infection. Cotrimoxazole does not replace the need for antiretroviral therapy.

Monitoring and evaluation
In order to monitor progress towards the delivery of comprehensive AIDS treatment, care and support, National programmes should assess the extent to which the range of HIV related care services are being implemented and set clear targets for children. Cotrimoxazole prophylaxis is an essential health intervention that needs to be included in child health services (e.g. including TB services).

The abstract of the article is taken from ‘The Lancet’ and joint WHO/UNAIDS/UNICEF statement on use of cotrimoxazole as prophylaxis in HIV exposed and HIV infected children