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Keep taking the tablets: low-cost antibiotic reduces hospitalisation and death of HIV-infected children on antiretroviral therap

02 January 2014

A daily dose of a low-cost antibiotic called cotrimoxazole reduces illness among HIV-positive children in Africa, even after several years of HIV treatment. Not only does cotrimoxazole reduce the chances of children needing hospital treatment, it also saves the health system money. These findings come from the ARROW trial in Uganda and Zimbabwe, which looked at whether HIV-infected children taking antiretroviral therapy (ART) should also continue taking cotrimoxazole, or stop taking it once their immune system has recovered on ART. The results were published today in the New England Journal of Medicine.

Previous trials in Africa showed that cotrimoxazole prophylaxis reduces death and illness in children who are not yet on ART (pdf, 142kb), as it helps prevent infections while their immune systems are weak. Once children have been on ART for several years, and their immune system has recovered, it was less clear whether they still needed to take this antibiotic as well.

The ARROW trial is the first randomised controlled trial to look at whether HIV-positive children in Africa can stop taking cotrimoxazole once they are on ART and their immune system has recovered. It involved 760 children from Uganda and Zimbabwe, who had already been on ART for an average of two years.

The trial found that hospitalisation or death was 64% higher in children who stopped taking cotrimoxazole, regardless of how old they were. Even children with the strongest immune systems benefited from continuing to take cotrimoxazole. Those who stopped taking the drug were more likely to have to go to hospital because of infections such as malaria, pneumonia, sepsis and meningitis.

Cotrimoxazole is already part of national and international guidelines for children with HIV, although many guidelines suggest that it can be stopped once a child’s immune system has recovered. We now know that this is not the case: children should continue to take cotrimoxazole even once their CD4 count (a measure of the strength of their immune system) has increased.  The problem is that cotrimoxazole is often unavailable in clinics in Africa because of stock-outs of medication.  Supply chains need to be improved to ensure that this low-cost drug is available for all children living with HIV to reduce illness even after several years of antiretroviral therapy.