Cotrimoxazole prophylaxis in adults infected with HIV in low-income countries

Two recent placebo-controlled trials of cotrimoxazole in HIV-infected adults, conducted by independent groups but in the same city (Abidjan, Côte d'Ivoire), have both shown important positive impacts. One study where cotrimoxazole or placebo was given to tuberculosis-HIV co-infected patients showed a significant reduction in mortality; the second study with a similar protocol, in HIV-infected patients without major co-morbidity at trial entry, showed a significant reduction in morbidity but no effect on mortality. These data have been interpreted by some as conclusive enough to recommend cotrimoxazole for all people with HIV/AIDS in Africa. Others have been more cautious, noting that Abidjan has an atypically low rate of cotrimoxazole resistance among bacterial pathogens, and consider more data are needed before such a sweeping policy decision can be made. Recent data from Senegal showed no benefit but this trial, like several others, was terminated prematurely because the investigators felt it unethical to continue after the Abidjan results were released. The situation is somewhat confused and confusing. This review attempts to put the current debate into context and to review the current position of cotrimoxazole in relation to other primary prophylaxis strategies in Africa.