Co-trimoxazole (CTX) Preventive Therapy (CPT) for HIV-Exposed/Infected infants and Children

Co-trimoxazole Preventive Therapy (CPT) protects the infant from Pneumocystis jiroveci pneumonia (PCP), toxoplasmosis and other bacterial diseases. It is the standard component of HIV care to reduce the morbidity and mortality of children less than five years of age.

All HIV-exposed infants should receive CPT from the age of 6 weeks until HIV is reliably excluded. In all those confirmed to be HIV-infected, CPT should be continued till 5 years of age. The recommended dose is 5 mg/kg/day of Trimethoprim (TMP) of co-trimoxazole (sulfamethoxazole and Trimethoprim combination) once daily.

Children with history of severe adverse reaction (grade 4 reaction) to co-trimoxazole or other sulfa drugs as well as children with G6PD (glucose-6-phosphate dehydrogenase deficiency) should not be initiated on CPT. The alternative drug , in this case, is Dapsone 2 mg/kg once daily (not to exceed 100 mg/day) orally.

Group	When to start Co- trimoxazole?	When to discontinue CPT prophylaxis?
All HIV-exposed infants/children	From 6 weeks of age (or at first encounter with health services)	HIV infection has been reliably excluded by a negative antibody test at 18 months, regardless of ARV initiation
All HIV-infected infants and children upto 5 years of age	Regardless of WHO stage or CD4 counts or CD4 %	At 5 years of age, when clinical or immunological indicators confirm restoration of the immune system for more than 6 months i.e. in a child > 5 years of age with a WHO T – stage 1 or 2 and CD4 count of > 350 cell/cmm on two occasions not less than 6 months apart
All HIV-infected children >5 years of age	WHO Stage 3 and 4 regardless of CD4 OR CD4 < 350 cells/cmm regardless of WHO staging	When clinical or immunological indicators confirm restoration of the immune system for more than 6 months i.e. in a child > 5 years of age with a WHO T- stage 1 or 2 and CD4 count of > 350 cells/cmm on two occasions not less than 6 months apart
As secondary prophylaxis	After completion of treatment for PCP	< 5 years old: do not stop > 5 years old: with a WHO T- stage 1 or 2 and CD4 count of >350 cells/cmm on two occasions not less than 6 months apart