E-DRUG: cotrimoxazole in African HIV+ patients
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[From Treatment-access <treatment-access@hivnet.ch>
with thanks; WB]
UNAIDS/WHO HAIL CONSENSUS ON USE OF COTRIMOXAZOLE FOR PREVENTION OF
HIV-RELATED INFECTIONS IN AFRICA - JOINT UNAIDS/WHO PRESS RELEASE
Geneva, 5 April 2000 - The Joint United Nations Programme on HIV/AIDS
(UNAIDS) and the World Health Organization (WHO) have welcomed the
consensus reached by experts to recommend the prophylactic use in
Africa of cotrimoxazole, a drug that wards off some of the
opportunistic infections to which HIV-infected people are prone.
"It was a difficult decision because the research is not definite
yet," said Peter Piot, Executive Director of UNAIDS. "But if there is
a real chance that using cotrimoxazole can improve the quality of life
of millions of HIV-infected Africans, then we have an obligation to
treat it seriously."
Widespread prophylactic, or preventive, use of cotrimoxazole in Africa
has been delayed by inconsistencies in research results. Two studies
in C�te d'Ivoire last year, one by French researchers and the other by
US scientists, demonstrated that the drug reduces the frequency of
opportunistic illnesses among HIV-infected people. In one of these
studies, a reduction in the number of AIDS-related deaths was
observed. Preliminary results of two recent UNAIDS-sponsored studies,
one from South Africa, and one from Malawi, confirmed that
cotrimoxazole is safe in HIV-infected people, and the Malawi study
indicated a significant beneficial effect on mortality. There has also
been controversy about whether this drug, widely used in the West,
should be used in Africa. In the West, cotrimoxazole is routinely used
to prevent pneumocystis carinii pneumonia or PCP, a parasitic type of
pneumonia common in industrialized countries among HIV-infected
people. Since PCP is not as common in Africa, the use of cotrimoxazole
was seen as questionable. Experts have argued with success, however,
that PCP is not the only parasitic infection against which
cotrimoxazole can work and so have advocated its use.
Common HIV-related infections in sub-Saharan Africa that can be
prevented by cotrimoxazole include certain bacterial pneumonias and
diarrhoeal diseases as well as certain septicemias. Cotrimoxazole may
also protect against toxoplasmosis, a parasitic brain disease, and
isosporiasis, a parasitic infection of the intestines.
"Because of the gravity of the HIV epidemic in Africa, this is the
best possible decision, based on the limited data that we have," said
Dr. Ebrahim Samba, Regional Director for WHO-Africa Region. "We will
proceed in a step-wise fashion while evaluating the effectiveness and
the impact of this intervention at country level."
The international meeting, held in Harare last week, was a joint
UNAIDS-WHO consultation and was attended by scientists, activists,
clinicians and heads of national AIDS programmes in Africa. They
recommended that cotrimoxazole be used for prophylaxis in adults and
children living with HIV or AIDS in Africa as part of a minimum
package of care. Criteria for the drug's use were established,
covering patient selection, drug regimens, duration of treatment,
follow-up, drug supply, education and training, monitoring for drug
resistance and adverse effects, evaluation of clinical effectiveness
and further research. Guidelines for implementing prophylaxis
programmes will be published shortly.
Cotrimoxazole costs between US$ 8 and US$ 17 per person per year for
prophylaxis. It is widely available throughout the continent and
preliminary analysis has shown that the use of cotrimoxazole
prophylaxis is a cost-effective intervention in Africa, particularly
if combined with increased access to voluntary counselling and testing
for HIV infection.
The other challenge faced in deciding whether to recommend the use of
cotrimoxazole in Africa is the risk of creating microbial resistance
to the drug if it is widely utilised as a prophylactic. When patients
in high-income countries develop infections resistant to a drug,
alternatives are often available. This is not as true in Africa, where
cotrimoxazole is one of the few affordable and widely available drugs
recommended for common infectious illnesses such as pneumonias in
children and bacterial diarrhoeas.
The issue of resistance remains important to Africa's use of the
drug. Scientists are aware that using cotrimoxazole in Africa is only
a medium-term solution. Future research will therefore include
investigation into alternative antimicrobial agents.
"It is essential to weigh the question of cotrimoxazole against the
two challenges of differing infections and possible resistance," said
Dr Piot. "But on a continent where antiretroviral drugs are still
beyond the reach of most, it is urgent to help prevent opportunistic
infections in people living with HIV/AIDS."
In sub-Saharan Africa, where 23.3 million people live with HIV or
AIDS, 13.7 million have already died because of the epidemic. In 1999
alone, there were 3.8 million new infections in the region.