A cotrimoxazole goal role for WHO?
by HDN Key Correspondent, Thailand
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On the eve of the International AIDS Conference held in Bangkok two years ago, a fellow Key Correspondent writing for Health and Development Networks noted that cotrimoxazole prophylaxis was not commonly being used by people living with HIV (PLHIV) in Asia. As the Toronto conference approaches this is a fitting time to consider what has changed.
Among the many actions that PLHIV can take while they are waiting for universal access to antiretroviral therapy to arrive, taking cotrimoxazole prophylaxis is the most readily available and affordable. Scientific studies and clinical experience have proven that taking a single tablet of double strength cotrimoxazole daily prevents opportunistic infections and saves lives. Cotrimoxazole can be taken by people living in the community without clinical supervision but it is best if it is offered as part of a package of services for PLHIV.
Cotrimoxazole prophylaxis is even more important for people with HIV who develop tuberculosis. People with dual infection, and who take cotrimoxazole, live longer and have a better quality of life. The ‘International Standards for Tuberculosis Care’ launched earlier this year incorporates cotrimoxazole prophylaxis into clear guidelines. If health workers do not give cotrimoxazole to patients who have dual infection then their practice falls below the current international standard of care. Recently a study from Uganda demonstrated that even the family members of people taking cotrimoxazole prophylaxis lead healthier lives.
Few HIV professionals doubt the usefulness of cotrimoxazole or oppose its wider use. Occasional challenges come from people who continue to clamour about potential drug resistance. They mostly live far removed from the everyday lives of PLHIV. The potential for resistance should be balanced against letting people continue to die without cotrimoxazole; in other words a person with HIV dying today compared with the possible harm to someone infected with a cotrimoxazole-resistant germ years from now.
Concerns have been raised that malaria parasites might develop resistance to cotrimoxazole, running the risk that other sulpha drugs might no longer work against them, though this concern appears to have decreased with the recently recommended use of artemisinin-containing combination drug regimens for malaria. People taking cotrimoxazole must, however, continue to take care not to take another sulpha-containing drug when they are trying to prevent or treat malaria.
Access to cotrimoxazole prophylaxis in the Asia Pacific region is still very low. Though it is now recommended in most national AIDS care and antiretroviral therapy guidelines, it is not generally used. There are no firm figures on its use as no targets have been set and thus no healthcare providers or governments feel compelled to report on usage. In Africa, too, there is little data on cotrimoxazole use. It has been several years since an estimate was made that 3% of adults living with HIV in Africa were taking cotrimoxazole.
In an effort to improve its image as an organisation leading the health sector response to HIV, the World Health Organization (WHO) is trying to increase its activities promoting human rights in relation to health. No other organisation can provide the same level of international guidance as to what must be done to help people exercise their right to health in HIV prevention and care. Cotrimoxazole prophylaxis is a vital aspect of HIV care on which the WHO is letting us all down. .
The WHO’s lack of urgency in actively promoting the use of cotrimoxazole for people with HIV is hardly news. In March 2000 both UNAIDS and the WHO recommended that cotrimoxazole prophylaxis should be used for PLHIV in Africa. That advice applied to all adults who had developed any opportunistic infection. Six years have passed. Despite the growth of the HIV epidemic in Asia, the World Health Organization headquarters still has not published any recommendations on cotrimoxazole use in Asia – or the rest of the world.
A WHO expert consultation that drafted new recommendations on cotrimoxizole prophylaxis was held over 14 months ago. Experts at the meeting recommended that the WHO develop clear and consistent messages about the need and value of cotrimoxazole prophylaxis and provide technical assistance for implementation of increased use. The meeting also recommended that targets be developed.
These actions have not happened.
In a letter to the team that authored the International Treatment Preparedness Coalition report ‘Missing the Target’, Dr Kevin de Cock, the new head of HIV/AIDS at WHO headquarters in Geneva, wrote: “… WHO will soon publish revised guidelines for … co-trimoxazole prophylaxis.” Months have passed and the guidelines are still not available.
Cotrimoxazole prophylaxis was identified as one of the building blocks of the ‘Three by Five’ initiative at its outset. The word cotrimoxazole, however, cannot be found in the final evaluation report of the WHO’s role in ‘Three by Five’. Cotrimoxazole makes few appearances in the final WHO ‘Three by Five’ report, and when it does, it is mostly in relation to malaria and tuberculosis.
The WHO can be commended for publishing guidance two years ago on cotrimoxazole prophylaxis for children with HIV. It has added clear recommendations on the use of cotrimoxazole prophylaxis to its draft TB/HIV comanagement manual for health workers treating people with both diseases. The TB department of the WHO has added 2004 data about the number of countries recommending cotrimoxazole prophylaxis in its Global Stop TB annual report this year. But not a single regional or global target for universal access to cotrimoxazole prophylaxis has yet been set.
Guidelines on cotrimoxazole prophylaxis need to be backed with promotion and targets need to be followed by action. Increasing access to cotrimoxazole prophylaxis is one area where the World Health Organization could take much more timely and effective action. In the meantime, people continue to die needlessly.
HDN Key Correspondent Team
Email: correspondents@hdnet.org
Web: www.healthdev.org/kc
HDN 2006 - Reproduction welcomed
*********************************
On the eve of the International AIDS Conference held in Bangkok two years ago, a fellow Key Correspondent writing for Health and Development Networks noted that cotrimoxazole prophylaxis was not commonly being used by people living with HIV (PLHIV) in Asia. As the Toronto conference approaches this is a fitting time to consider what has changed.
Among the many actions that PLHIV can take while they are waiting for universal access to antiretroviral therapy to arrive, taking cotrimoxazole prophylaxis is the most readily available and affordable. Scientific studies and clinical experience have proven that taking a single tablet of double strength cotrimoxazole daily prevents opportunistic infections and saves lives. Cotrimoxazole can be taken by people living in the community without clinical supervision but it is best if it is offered as part of a package of services for PLHIV.
Cotrimoxazole prophylaxis is even more important for people with HIV who develop tuberculosis. People with dual infection, and who take cotrimoxazole, live longer and have a better quality of life. The ‘International Standards for Tuberculosis Care’ launched earlier this year incorporates cotrimoxazole prophylaxis into clear guidelines. If health workers do not give cotrimoxazole to patients who have dual infection then their practice falls below the current international standard of care. Recently a study from Uganda demonstrated that even the family members of people taking cotrimoxazole prophylaxis lead healthier lives.
Few HIV professionals doubt the usefulness of cotrimoxazole or oppose its wider use. Occasional challenges come from people who continue to clamour about potential drug resistance. They mostly live far removed from the everyday lives of PLHIV. The potential for resistance should be balanced against letting people continue to die without cotrimoxazole; in other words a person with HIV dying today compared with the possible harm to someone infected with a cotrimoxazole-resistant germ years from now.
Concerns have been raised that malaria parasites might develop resistance to cotrimoxazole, running the risk that other sulpha drugs might no longer work against them, though this concern appears to have decreased with the recently recommended use of artemisinin-containing combination drug regimens for malaria. People taking cotrimoxazole must, however, continue to take care not to take another sulpha-containing drug when they are trying to prevent or treat malaria.
Access to cotrimoxazole prophylaxis in the Asia Pacific region is still very low. Though it is now recommended in most national AIDS care and antiretroviral therapy guidelines, it is not generally used. There are no firm figures on its use as no targets have been set and thus no healthcare providers or governments feel compelled to report on usage. In Africa, too, there is little data on cotrimoxazole use. It has been several years since an estimate was made that 3% of adults living with HIV in Africa were taking cotrimoxazole.
In an effort to improve its image as an organisation leading the health sector response to HIV, the World Health Organization (WHO) is trying to increase its activities promoting human rights in relation to health. No other organisation can provide the same level of international guidance as to what must be done to help people exercise their right to health in HIV prevention and care. Cotrimoxazole prophylaxis is a vital aspect of HIV care on which the WHO is letting us all down. .
The WHO’s lack of urgency in actively promoting the use of cotrimoxazole for people with HIV is hardly news. In March 2000 both UNAIDS and the WHO recommended that cotrimoxazole prophylaxis should be used for PLHIV in Africa. That advice applied to all adults who had developed any opportunistic infection. Six years have passed. Despite the growth of the HIV epidemic in Asia, the World Health Organization headquarters still has not published any recommendations on cotrimoxazole use in Asia – or the rest of the world.
A WHO expert consultation that drafted new recommendations on cotrimoxizole prophylaxis was held over 14 months ago. Experts at the meeting recommended that the WHO develop clear and consistent messages about the need and value of cotrimoxazole prophylaxis and provide technical assistance for implementation of increased use. The meeting also recommended that targets be developed.
These actions have not happened.
In a letter to the team that authored the International Treatment Preparedness Coalition report ‘Missing the Target’, Dr Kevin de Cock, the new head of HIV/AIDS at WHO headquarters in Geneva, wrote: “… WHO will soon publish revised guidelines for … co-trimoxazole prophylaxis.” Months have passed and the guidelines are still not available.
Cotrimoxazole prophylaxis was identified as one of the building blocks of the ‘Three by Five’ initiative at its outset. The word cotrimoxazole, however, cannot be found in the final evaluation report of the WHO’s role in ‘Three by Five’. Cotrimoxazole makes few appearances in the final WHO ‘Three by Five’ report, and when it does, it is mostly in relation to malaria and tuberculosis.
The WHO can be commended for publishing guidance two years ago on cotrimoxazole prophylaxis for children with HIV. It has added clear recommendations on the use of cotrimoxazole prophylaxis to its draft TB/HIV comanagement manual for health workers treating people with both diseases. The TB department of the WHO has added 2004 data about the number of countries recommending cotrimoxazole prophylaxis in its Global Stop TB annual report this year. But not a single regional or global target for universal access to cotrimoxazole prophylaxis has yet been set.
Guidelines on cotrimoxazole prophylaxis need to be backed with promotion and targets need to be followed by action. Increasing access to cotrimoxazole prophylaxis is one area where the World Health Organization could take much more timely and effective action. In the meantime, people continue to die needlessly.
HDN Key Correspondent Team
Email: correspondents@hdnet.org
Web: www.healthdev.org/kc
HDN 2006 - Reproduction welcomed
posted by AIDS-Care-Watch at 9:20 pm
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