Report on the Global HIV/AIDS epidemic

Care and support for people living with HIV/AIDS

Better prospects for preventing infections in those with HIV
Given the limited diagnostic facilities available in developing countries and the high
costs of many drugs for treating opportunistic infections, let alone antiretrovirals, the
option of prevention is receiving renewed attention. The bulk of evidence now suggests that a few relatively inexpensive drugs could help ward off severe illness and
add months, if not years, to the lives of HIV-positive people in even the poorest
developing countries. Indeed, preventive drugs had begun to prolong survival in the
high-income countries even before antiretroviral therapy was available.
One drug is isoniazid, which has been shown to be effective in warding off 60% of
active tuberculosis episodes in people with HIV. In at least one study, isoniazid prevention prolonged life significantly for those who were infected with both HIV and the
bacillus that causes tuberculosis. A simple regimen costs on average just a few
cents a day for both the medicine and the health services involved.
Tuberculosis prophylaxis is especially important because in half the cases HIVinfected individuals develop a form of TB which cannot be easily diagnosed and
which thus goes untreated. Diagnosing disseminated tuberculosis requires sophisticated laboratory equipment that is largely unavailable in many of the poorer developing countries. This is why UNAIDS and WHO have recommended since 1998 that
a simple and inexpensive regimen for preventing tuberculosis should be part of the
essential care package for people with HIV (see Table 1, page 98).
New developments point the way to preventing other severe infections.
Cotrimoxazole - a pill combining an antibiotic and a sulfa drug which has helped
prevent Pneumocystis carinii pneumonia, the biggest AIDS-related killer in highincome countries - was tested for its preventive impact in Cote d'lvoire. In one study
in Abidjan, where the drug costs of a 12-month regimen were just US$ 17.50, cotrimoxazole prophylaxis resulted in significantly fewer severe infections (as measured
by hospital admissions). In another study, cotrimoxazole warded off infections so
successfully that it extended life by half a year. The drug combination appeared to
be effective in preventing some bacterial pneumonias, diarrhoeal diseases and
infections of the blood, and possibly toxoplasmosis (a parasitic brain disease) and
isosporiasis (a parasitic infection of the intestines).
In the light of these hopeful findings it is urgent to implement cotrimoxazole regimens in sub-Saharan Africa as part of the essential care package for adults and children living with HIV (see Box 20). At the same time, scientists will need to keep careful watch so that the value of this drug combination is not undermined by the development of resistance to it.

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