Cotrimoxazole reduces mortality and morbidity in HIV-positive children: joint WHO/UNAIDS/UNICEF statement

Polly Clayden, HIV i-Base

WHO, UNAIDS and UNICEF, guided by recent findings, have agreed to modify as an interim the current recommendations [1] for cotrimoxazole prophylaxis in children.

This is based upon data – recently published in the Lancet [2] – from a double-blind randomised placebo-controlled trial in 541 children with HIV aged 1-14 years in Zambia, an area with high levels of bacterial resistance to this drug. After a median follow-up of 19 months, fewer children (28% vs 42%) had died in the co-trimoxazole group than in the placebo group.

It reads: “Cotrimoxazole remains important even with increasing access to ART, as it use can improve survival independently of specific HIV treatment. Current recommendations suggest it should be used before children require ARVs because it may even postpone the time at which ART needs to be started”.

The statement recommends that cotrimoxazole should be given to:

All HIV exposed children (children born to HIV infected mothers) from 4-6 weeks of age (whether or not part of a prevention of mother-to-child transmission [PMTCT] programme)

Any child identified as HIV-infected with any clinical signs or symptoms suggestive of HIV, regardless of age or CD4 count.

The statement also makes recommendations on duration of prophylaxis, discontinuation, toxicity, dosing, follow up and other operational issues.


These results provide a valuable additional reason for HIV testing children with clinical features suggestive of HIV infection, as this is an affordable intervention that is available right now.

However it should be said that the 50% reduction in mortality seen with cotrimoxazole needs to be compared with the 500% reduction in mortality in HIV infected children given triple combination antiretroviral therapy. [3]


  1. Provisional WHO/Unaids Secretariat Recommendations Unaids On The Use Of Cotrimoxazole Prophylaxis In Adults And Children Living With HIV/Aids In Africa.
  2. Chintu C, Bhat GJ, Walker AS, et al. Co-trimoxazole as prophylaxis against opportunistic infections in HIV-infected Zambian children (CHAP):a double-blind randomised placebo-controlled trial. Lancet 2004; 364: 1865–71.
  3. Gibb DM et al for the Collaborative HIV Paediatric Study (CHIPS). Decline in mortality, AIDS, and hospital admissions in perinatally HIV-1 infected children in the United Kingdom and Ireland. BMJ Volume 327 1 November 2003.

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