The World Health Organization (WHO) guidelines recommend that all HIV-exposed infants, including HIV-exposed uninfected infants (HEUs), born to HIV positive mothers receive co-trimoxazole (CTX) prophylaxis, commencing at 4–6 weeks of age and continued until HIV infection can be excluded. This guideline was based on efficacy data from a single trial studying antiretroviral-naïve, HIV positive children who were protected from Pneumocystis pneumonia (PCP) by CTX (Chintu et al., 2004). Guidelines for CTX prophylaxis were established at a time when there was limited access to HIV diagnostic testing to identify infants living with HIV (testing could only occur after 24 months of age), and prevention of mother-to-child transmission of HIV (PMTCT) drug interventions were less effective than current regimens.

Previous studies have shown inconsistent effectiveness of CTX prophylaxis against malaria and bacterial infections in some populations (Coutsoudis et al., 2011; Coutsoudis et al., 2005; Sandison et al., 2011; Taha et al., 2011; Thera et al., 2005). Although CTX appears to convey benefit in relation to reduction in malarial morbidity, there is inadequate evidence supporting the benefit of CTX prophylaxis in breastfed HEU infants, in terms of overall morbidity and mortality.

Currently, South Africa’s well-established PMTCT program has resulted in low vertical HIV transmission rates, with routine early infant diagnostic testing resulting in timeous lifelong antiretroviral treatment (ART) and CTX prophylaxis for HIV infected infants (Barron et al., 2013; Goga et al., 2018; Sherman et al., 2014). Since there is greatly improved surveillance and so few infants being newly infected with HIV, South Africa needed to consider the appropriateness and cost-effectiveness of a public health “blanket’ approach of providing CTX prophylaxis to all HIV-exposed infants, particularly with recent concerns regarding antimicrobial resistance (Coutsoudis et al., 2010; Gill et al., 2004; Weerasuriya et al., 2010).

View the complete Changing the Cotrimoxazole Prophylaxis Guidelines for HIV Exposed-Uninfected Infants -Policy Brief