Table 5.1Criteria for initiating and discontinuing co-trimoxazole prophylaxis

PopulationRecommendations
Criteria for initiating co-trimoxazole prophylaxisCriteria for discontinuing co-trimoxazole prophylaxis
Adults (including pregnant women) with HIVInitiate in everyone with severe or advanced HIV disease (WHO clinical stage 3 or 4) or CD4 ≤350 cells/mm3a

In settings with high prevalence of malaria and/or severe bacterial infectionsb: initiate for everyone regardless of WHO clinical stage or CD4 cell count		May be discontinued for those who are clinically stablec, with evidence of immune recovery and/or viral suppression on ARTd,e

In settings with a high prevalence of malaria and/or severe bacterial infections: should be continued
Children and adolescents with HIVInitiate for everyone regardless of WHO clinical stage or CD4 cell count As a priority: (1) initiate for everyone younger than 5 years regardless of WHO clinical stage or CD4 cell count; (2) initiate for everyone older than 5 years with severe or advanced HIV disease (WHO clinical stage 3 or 4) or a CD4 count ≤350 cells/mm3In settings with a high prevalence of malaria and/or severe bacterial infections: should be continued until adulthood In settings with a low prevalence of both malaria and severe bacterial infections: may be discontinued for those older than 5 years who are clinically stable, with evidence of immune recoveryf and/or viral suppression on ART
HIV-exposed but uninfected infantsInitiate for everyone starting at 4–6 weeks after birthUntil the risk of HIV transmission ends or HIV infection is excludedg
People living with HIV and TBhInitiate for everyone with active TB regardless of CD4 cell countUntil adult or children criteria for discontinuation are met
a

This group is also given priority for ART initiation (as recommended for ART in the 2013 WHO consolidated guidelines (47).

b

Settings in which malaria and/or severe bacterial infections are highly prevalent include low- and middle-income countries with high rates of mortality for children younger than 5 years old (48).

c

Clinically stable adults are defined as individuals receiving ART for at least 1 year without any new WHO clinical stage 2, 3 or 4 events.

d

CD4 count >350 cells/mm3, with viral load suppression, is considered immune recovery (some countries may adopt a threshold of CD4 count >500 cells/mm3).

e

WHO recognizes that, in settings with a low prevalence of malaria and severe bacterial infection settings where co-trimoxazole is used primarily as prophylaxis for some HIV-associated opportunistic infections (Pneumocystis jirovecii pneumonia and toxoplasmosis), guidelines exist for discontinuing co-trimoxazole in adults with HIV infection when there is evidence of viral suppression and immune recovery at a CD4 count >200 cells/mm3 and they have been receiving ART for at least 1 year.

f

Parameter for immune recovery among children >5 years old: CD4 count >350 cells/mm3, with viral load suppression.

g

In settings with high malaria transmission, consideration may be given to extending co-trimoxazole prophylaxis among HIV-exposed uninfected infants up to 2 years of age.

h

Recommendation maintained from WHO policy on collaborative TB/HIV policy activities: guidelines for national programmes and other stakeholders (49).

From: 5, THE USE OF CO-TRIMOXAZOLE PROPHYLAXIS FOR HIV-RELATED INFECTIONS AMONG ADULTS, ADOLESCENTS AND CHILDREN

Cover of Guidelines on Post-Exposure Prophylaxis for HIV and the Use of Co-Trimoxazole Prophylaxis for HIV-Related Infections Among Adults, Adolescents and Children: Recommendations for a Public Health Approach
Guidelines on Post-Exposure Prophylaxis for HIV and the Use of Co-Trimoxazole Prophylaxis for HIV-Related Infections Among Adults, Adolescents and Children: Recommendations for a Public Health Approach: December 2014 supplement to the 2013 consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection.
Geneva: World Health Organization; 2014 Dec.
Copyright © World Health Organization 2014.

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