Septrin: Its role among people living with HIV

In the past months, there was a stock out of Septrin (cotrimoxazole), causing considerable confusion, more so among those that depend on it for their livelihood; people living with HIV.
The confusion seems to rest on the role that the widely prescribed antibiotic has in the treatment of HIV and Aids.
Septrin is a drug used in anti-retroviral therapy. Unlike antiretroviral drugs (ARVs) that disrupt the reproduction of the HIV virus, Septrin is a combination antibiotic that fights against opportunistic infections that those living with HIV are vulnerable to until their viral load is made low.
On May 16, 2018, the Daily Monitor newspaper reported that the National Medical Stores (NMS) had run out of Septrin, putting more than one million people living with HIV at risk of acquiring opportunistic infections.
On May 22, 2018, the New Vision newspaper reported “HIV drug shortage hits nation,” and Septrin was referenced.
The paper later reported on May 23, 2018, that the Ugandan government had received Shs 14.4 billion from Global Fund to resupply NMS with Septrin.
While Ministry of Health reported that Septrin is not a HIV drug as reported in the news reports, TASO Pharmacy Services Advisor, Isaac Mutabaazi, asks “Why is it that for years we have kept patients on an unnecessary drug? Why is it that a claim about Septrin’s minor importance comes in after the event of shortages? The guidelines should have come in even when the stocks were available.”
Dr Sabrina Bakeera-Kitaka, a senior lecturer as well as paediatric and adolescent health specialist in the Department of Paediatrics at Makerere University College of Health Sciences, highlights the role of Septrin amid the shrinking HIV funding envelope and anecdotal non-adherence among patients who are virally suppressed and immunologically stable;
HIV damages the body’s immune system, making secondary (or opportunistic) infections more common. Treatment and prevention of such infections is integral to the management of patients with HIV infection. Co-trimoxazole (Septrin) is a preventative treatment that has a wide range of action against common bacteria, parasites, fungi and yeasts.
As part of a minimum care package, UNAIDS/ WHO recommends Septrin preventive treatment for HIV-infected adults with indicative disease (WHO stage II, III or IV), or people living with HIV that show no symptoms yet have CD4 counts less than or equal to 500 cells/µl, and for all HIV-positive pregnant women after the first trimester.
Septrin is also recommended for use in children with proven HIV infection and infants exposed to HIV (from six weeks of age until infection with HIV is ruled out). The use of septrin (CTX) as preventative treatment against opportunistic infections among HIV-infected persons is part of the standard of care recommended by the World Health Organisation (WHO) Guidelines. In resource limited settings, once HIV infected patients have commenced antiretroviral therapy (ART), the benefits of continued preventive CTX medication are not known.
Nonetheless, primary preventative treatment is given to prevent anticipated disease, and secondary preventative treatment is given to prevent a repeat episode of the illness such as when the patient has suffered from Pneumocycytis Jerovici Pneumonia (PJP).
Various studies have been done to help answer this CTX question such as the ARROW Trial among children and the COSTOP study among adults.

The Uganda HIV guidelines of 2016 state:
Co-trimoxazole Preventive Therapy (CPT) can reduce the risk of malaria, diarrhoea and pneumonia caused by bacterial infections; hospitalisation; and mortality. It is also the mainstay of prevention of PJP.
• All people living with HIV should receive CPT for life unless they have allergy to sulphur-containing drugs or toxicity to septrin.
• All pregnant women should receive CPT irrespective of gestation age and should continue through breastfeeding and thereafter for life. Additional intermittent preventive treatment for malaria using sulfadoxine-pyrimethamine (SP) is not required for pregnant women on CPT.
The cost of the Septrin versus the benefit of giving it to all patients irrespective of their immune recovery and suppressed viral load while on antiretroviral therapy has been a continued focus for debate leading to the recommendation by the WHO to allow countries to have specific national guidelines.
The aids Control Programme of the Ministry of Healthy with support from the National aids Guidelines Committee (NAC) will soon issue updated 2018 HIV Guidelines, including on the use of CTX. These guidelines are well researched and are based on scientific grounds.