CO -TRI MOX A ZOLE PROPH Y L A X I S

FOR H I V- E X POS E D
A N D H I V- I N FECTE D I N FA NT S
A N D CH I LD RE N
Pr ac t i c a l a p p r oac h e s
to i m p l e m e n t a t i o n a n d s c a l e u p

WHO Library Cataloguing-in-Publication Data

Co-trimoxazole prophylaxis for HIV-exposed and HIV-infected infants

and children: Practical approaches to implementation and scale up
1. Trimethoprim-sulfamethoxazole combination - therapeutic use. 2. HIV infections - drug therapy. 3. AIDS-related
opportunistic infections - prevention and control. 4. Child. 5. Infant. I. World Health Organization. II. UNICEF.
ISBN 978 92 4 159863 7

(NLM classification: WC 503.2)

World Health Organization and UNICEF 2009

All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health
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The mention of specific companies or of certain manufacturers products does not imply that they are endorsed
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incurred as a result of its use.
Cover photo credit: UNICEF/NYHQ2006-1375/Pirozzi
All text photo credits: Smiley N.Pool

CO -TRI M OX A ZO LE PRO PH Y L A X I S
FO R H I V- E X POS E D
A N D H I V- I N FECTE D I N FA NT S
A N D CH I LD R E N
Pr ac t i c a l a p p r oac h e s
to i m p l e m e n t a t i o n a n d s c a l e u p

This document was written on behalf of the Expanded Inter-Agency Task Team (IATT) on Prevention
of HIV Infection in Pregnant Women, Mothers and their Children and with the collaboration of multiple
organizations working to improve pediatric HIV prevention, care and treatment.

ACK N OW LE DG E M E NT S
We gratefully acknowledge the work of Elizabeth Preble for research associated with this guide and
for providing the first complete drafts.
The contributions of the following individuals who assisted in further developing, reviewing and editing
this document are also gratefully acknowledged: Elaine Abrams, Stephen Arpadi, Jane Briggs, Nancy
Calles, Miriam Chipimo, Siobhan Crowley, Patricia Doughty, Ren Ekpini, Gloria Ekpo, Shaffiq Essajee,
Kathy Ferrer, Robert Ferris, Mary Lyn Field-Nguer, Robert Gass, Janet Kayita, Mary Lou Lindegren,
Ronnie Lovich, Chewe Luo, Bandana Malhotra, Justin Mandala, Elizabeth Preble, Emilia Rivadeneira,
Paul Roux, Peter Salama, Nathan Shaffer, Diana Silimperi, Michael Tolle, Renee van de Weerdt and
Helena Walkowiak.
UNICEF and WHO on behalf of the Inter-Agency Task Team on Prevention of HIV Infection in Pregnant
Women, Mothers and their Children would like to express special gratitude to the writing committee
that worked to develop successive drafts of this publication: Siobhan Crowley, Mary Lyn Field-Nguer
and Robert Gass.
UNICEF and WHO also acknowledge the efforts and dedication of Siobhan Crowley and Robert Gass
for their overall coordination of this project and bringing this publication to fruition.

iii

ACRO N Y M S A N D A B B R E V I ATI O N S
ANC

antenatal care

ARI

acute respiratory infection

ART

antiretroviral therapy

ARV

antiretroviral

BIPAI

Baylor International Pediatric AIDS Initiative

BUFMAR

Bureau des Formations Mdicales Agres au Rwanda

CAMERWA

Centrale dAchat de Mdicaments Essentiels du Rwanda

CBO

community-based organization

CHAP

Children with HIV Antibiotic Prophylaxis (study)

CHER

Children with HIV Early Antiretroviral Therapy (study)

CPDS

Coordinated Procurement and Distribution System

DBS

dried blood spot

EML

essential medicines list

GMP

Good Manufacturing Practices

HMIS

health management information systems

IMAI

Integrated Management of Adolescent and Adult Illness

IMCI

Integrated Management of Childhood Illness

IMNCI

Integrated Management of Neonatal and Childhood Illness

MCH

maternal and child health

MNCH

maternal, newborn and child health

MNH

maternal and newborn health

MOH

Ministry of Health

MSH

Management Sciences for Health

MTCT

mother-to-child transmission

NGO

nongovernmental organization

NVP

nevirapine

OI

opportunistic infection

PCP

Pneumocystis jiroveci pneumonia

PEPFAR

US Presidents Emergency Plan for AIDS Relief

PITC

provider-initiated HIV testing and counselling

PMTCT

prevention of mother-to-child transmission (of HIV)

UNAIDS

Joint United Nations Programme on HIV/AIDS

UNICEF

United Nations Childrens Fund

WHO

World Health Organization

iv

CO NTE NT S
AC K N OW LE D G E M E NT S .. ............. ....................................................................................................................................... i i i
AC RO N Y M S A N D A B B R E V I ATI O N S . .............................................................................................................. i v
E X ECUTI V E S U M M A RY ...................................................................................................................................................... v i i
I . I NTRO D UCTI O N .. ..................................................................................................................................................................... 1
I I . H I V I N FECTI O N I N I N FA NT S A N D CH I LD R E N .................................................................. 3

A. Epidemiology and clinical overview........................................................................................................................................................................... 3

B. Access to diagnosis and treatment of HIV....................................................................................................................................................... 3

C. Access to co-trimoxazole prophylaxis for infants and children............................................................................................ 4

I I I . R ATI O N A LE A N D R ECO M M E N DATI O N S . .................................................................................... 5

A. Rationale........................................................................................................................................................................................................................................................ 5

B. WHO recommendations. .......................................................................................................................................................................................................... 6

C. Adherence. .................................................................................................................................................................................................................................................. 6

D. Discontinuation of co-trimoxazole prophylaxis........................................................................................................................................... 7

I V. C H A LLE N G E S .. ............................................................................................................................................................................. 8
V. K E Y S TR ATEG I E S FO R S CA LI N G U P ................................................................................................ 9

Government leadership, ownership and accountability.......................................................................................................................... 9

Integration of co-trimoxazole prophylaxis into existing services.............................................................................................. 12

Use of available entry points to initiate co-trimoxazole prophylaxis.................................................................................... 15

Reliable procurement and supply management mechanisms.................................................................................................... 19

Strengthened community-based capacity........................................................................................................................................................... 22

Strengthened monitoring and evaluation systems...................................................................................................................................... 24

V I . CO N CLU S I O N ........................................................................................................................................................................... 2 6
APPENDICES........................................................................................................................................................................................................................................................... 27
Appendix A: WHO recommendations for co-trimoxazole prophylaxis for infants and children................27
Appendix B: Generic HIV algorithm used for the Integrated Management

of Childhood Illness (IMCI) programme........................................................................................................................................ 30
Appendix C: Zambia child health card...................................................................................................................................................................................31
Appendix D: Sample dosing card for co-trimoxazole prophylaxis (Columbia University)................................ 33
Appendix E: Rapid assessment tool for scaling up co-trimoxazole prophylaxis......................................................... 34
Appendix F: Assessment of staffing needs................................................................................................................................................................... 38
Appendix G: Resources for co-trimoxazole prophylaxis............................................................................................................................... 39

R E FE R E N CE S .. ..................................................................................................................................................................................... 4 0

vi

E X ECUTI V E S U M M A RY
Co-trimoxazole prophylaxis is safe, inexpensive and highly effective in reducing morbidity and mortality
among HIV-infected infants and children. The World Health Organization (WHO) recommends that all
HIV-exposed infants be started on co-trimoxazole prophylaxis at four to six weeks of age, in order
to provide adequate prevention against early opportunistic infections (OIs). This is particularly critical
for HIV-infected infants. Data from a randomized clinical trial conducted in Zambia demonstrated
the effectiveness of co-trimoxazole prophylaxis in reducing mortality and morbidity among
HIV-infected children, despite high levels of bacterial resistance. Other studies have also demonstrated
the effectiveness of co-trimoxazole prophylaxis in HIV-infected children, adolescents and adults
across the spectrum of CD4 counts, and across varying levels of bacterial resistance. Benefits to be
accrued from co-trimoxazole prophylaxis are particularly important in resource-limited settings where
access to effective services for prevention of mother-to-child transmission (PMTCT) of HIV, effective
infant-feeding interventions, early diagnostic services and antiretroviral therapy (ART) for children
remain limited.
Globally, in 2007, about 2 million children below the age of 15 years were living with HIV. In that year
alone, 370 000 children were newly infected with HIV, more than 90% of them as a result of mother-tochild transmission (MTCT) of HIV, and 270 000 children died of HIV-related causes. While HIV care and
treatment services for HIV-infected children are slowly expanding in resource-constrained settings,
they are still very limited and lag behind treatment services available for adults.
An important component of the HIV care and treatment package for children is the provision of cotrimoxazole prophylaxis. This widely available, inexpensive antibiotic is recommended for HIV-exposed
or -infected children to prevent the development of serious, often fatal, OIs, notably Pneumocystis
jiroveci pneumonia (PCP) in young HIV-infected infants. However, despite the fact that countries have
developed and put in place policies to support the scale up and implementation of co-trimoxazole
prophylaxis for infants and children, and that it is inexpensive, life-saving, safe and theoretically simple
to deliver, the United Nations Childrens Fund (UNICEF), WHO and partners estimate that in 2008, only
8% of children exposed to HIV were initiated on co-trimoxazole prophylaxis by two months of age.
One of the main challenges countries must address in order to scale up co-trimoxazole prophylaxis is
the absence of mechanisms to systematically identify and follow up HIV-exposed infants at and after
birth. If HIV-infected children are to be identified early in the course of their disease a prerequisite
for receiving co-trimoxazole prophylaxis and early ART systems need to be in place to ensure that
health workers consider the possibility of HIV infection in infants at birth and at all clinic or other
health encounters thereafter. Antenatal messages for HIV-infected women need to routinely include
anticipatory guidance aimed at improving postnatal follow up of motherinfant pairs through education
and information of parents and caregivers It is also critical to inform and mobilize communities
to ensure that HIV-exposed infants and children are identified and families are aware of available
services for prevention and treatment for young infants and children, and the benefits of early use of
care services.

vii

This document provides a brief review of evidence supporting the use of co-trimoxazole prophylaxis
in children and summarizes common barriers to implementation. It proposes specific actions and
strategies needed for scaling up co-trimoxazole prophylaxis, including the following:
1. Government leadership, ownership and accountability for provision of co-trimoxazole
prophylaxis to HIV-exposed and -infected infants and children. This entails developing
policies, setting national targets and making budgeted national plans to reach infants and children
in need;
2. Delivery of co-trimoxazole prophylaxis for children through such existing services as
HIV and maternal, newborn and child health (MNCH), and decentralization of delivery to the
lowest appropriate, effective and feasible level of the health-care system;
3. Maximized use of all available entry points to ensure timely initiation of co-trimoxazole
prophylaxis. This will be facilitated through the use of provider-initiated HIV testing and counselling
(PITC) to identify HIV-exposed and -infected infants and children, use of child health cards with
HIV-specific information, and outreach services including immunization and home-based care;
4. Developing reliable national- and district-level procurement and supply management
mechanisms that ensure a consistent supply of co-trimoxazole for paediatric co-trimoxazole
prophylaxis needs;
5. Strengthened community-based capacity to identify HIV-exposed and -infected infants
and children, and provide referrals for testing, care (including initiation and continuation of cotrimoxazole prophylaxis) and treatment;
6. Strengthened monitoring and evaluation systems to support the provision of high-quality
care for children who are HIV-infected or -exposed, including the provision of co-trimoxazole
prophylaxis.

viii

I . I NTRO DUCTI O N
Co-trimoxazole prophylaxis is safe, inexpensive and highly effective in reducing morbidity and
mortality among HIV-infected infants and children, as well as in adolescents and adults. Ideally, all
infants exposed to HIV should be started on co-trimoxazole prophylaxis during the first four to six
weeks of life, as recommended by the World Health Organization (WHO). This period is particularly
critical for HIV-infected infants. Providing co-trimoxazole prophylaxis protects against serious, often
fatal, opportunistic infections (OIs) and leads to improvement in the quality of life of HIV-infected
infants while reducing the burden of care on health-care systems and caregivers. In situations where
antiretroviral therapy (ART) is not readily available, the use of co-trimoxazole prophylaxis will increase
the chances of survival of HIV-infected infants until ART can be initiated. This is particularly important
in resource-limited settings where access to effective services for prevention of mother-to-child
transmission (PMTCT) and ART remains limited.

Key points
Co-trimoxazole prophylaxis can cut mortality in half and reduce hospital admissions of
children.
Co-trimoxazole prophylaxis is inexpensive, and costs about US$ 0.03 per child per day,
or about US$ 10/child/year.
In 2008, 1.4 million women with HIV gave birth in low- and middle-income countries.
All babies born to these mothers with HIV should receive co-trimoxazole prophylaxis but
the estimated coverage of such infants is only 8%.
Globally, in 2007, about 2 million children below the age of 15 years were living with HIV. In that
year alone, 370 000 children were newly infected with HIV, over 90% as a result of mother-to-child
transmission (MTCT), and 270 000 children died of HIV-related causes.1 Most of these deaths occurred
in sub-Saharan African countries where seroprevalence rates among women of reproductive age are
extremely high and where health services, including programmes that can prevent and treat paediatric
HIV, are still limited.
In resource-rich settings, the rate of HIV transmission from HIV-infected pregnant women who have
access to a comprehensive package of PMTCT services to their infants is less than 2%. 2 Unfortunately,
in 2008, antiretrovirals (ARVs) or ART to prevent MTCT, a crucial component of PMTCT services,
reached only about 45% of pregnant women with HIV in low- and middle-income countries.4 In
addition, most women received prophylaxis with only single-dose nevirapine (NVP), a regimen that is
less effective than combination ARV regimens in reducing MTCT.
While HIV care and treatment services for HIV-infected children in resource-constrained settings are
slowly expanding, they are still very limited and lag behind treatment services available for adults.
The widely available antibiotic co-trimoxazole is an important preventive element of HIV care and is
recommended for the prevention of OIs, notably Pneumocystis jiroveci pneumonia (PCP), and its use
for this indication is referred to as co-trimoxazole prophylaxis.

I
Despite the existence of national policies for co-trimoxazole prophylaxis and the fact that it is
inexpensive, lifesaving, widely available, safe and theoretically easy to deliver, the United Nations
Childrens Fund (UNICEF), WHO and partners estimate that in 2008, only about 8% of children
exposed to HIV were initiated on co-trimoxazole prophylaxis by two months of age.4
This document proposes actions needed to scale up co-trimoxazole prophylaxis. It is intended:
to provide practical information on the role of co-trimoxazole prophylaxis in maternal and child
health (MCH) and HIV programming,
to review current barriers to rapid, effective scaling up of co-trimoxazole prophylaxis, and
to provide strategies and tools to facilitate scale up.
The principal audiences for this document include national, provincial and district-level programme
managers, planners, trainers and implementing partners.

II

I I . H I V I N FECTI O N I N I N FA NT S
A N D CH I LD R E N
A . E p i d e m i o l o g y a n d c l i n i c a l ove r v i ew
Globally, over 90% of children with HIV live in sub-Saharan Africa, where seroprevalence rates among
women of reproductive age remain high. The vast majority of these infants were infected in utero,
during delivery or after birth through breastfeeding. For infants infected during pregnancy or delivery,
HIV disease progression is particularly rapid, with mortality rates exceeding 50% in the first year of life.
Access to co-trimoxazole prophylaxis and early ART is life-saving for such infants.
Just as in adults, HIV in children damages the immune system; thus, opportunistic and other infections
are more common and more severe. In addition, children in resource-limited settings are exposed to a
greater burden of pathogens associated with early morbidity and mortality, irrespective of HIV status.
Co-trimoxazole prophylaxis can prevent the development of some of the most serious opportunistic
and common childhood infections.
HIV-uninfected infants born to HIV-infected women also have greater morbidity and mortality than
HIV-unexposed infants and children. Many infections in children born to mothers with HIV, regardless
of the infants eventual HIV status, can be prevented by timely initiation of co-trimoxazole prophylaxis.
To maximize the benefits of co-trimoxazole prophylaxis, it should be started before HIV
infection can be confirmed and prior to the development of HIV-related signs or symptoms.

B . Ac c e s s to d i a g n os i s a n d t r e a t m e n t o f H I V
It is essential to institute systems which ensure that infants known to be HIV exposed are followed
regularly and tested using an HIV viral test at four to six weeks after birth to identify HIV infection
before it becomes symptomatic. This would enable early initiation of ART for HIV-infected infants.
Exposed infants also need to have adequate infant-feeding support and counselling, as well as other
important HIV care and treatment interventions.
Access to HIV viral tests (which are recommended for the diagnosis of HIV in infants) has increased in
recent years, largely as a result of the introduction of dried blood spot (DBS) specimen collection on
filter paper. When test results are promptly provided and acted upon, and treatment is initiated early
in infancy, HIV-infected infants experience significantly reduced morbidity and mortality (Children with
HIV Early Antiretroviral Therapy [CHER] study).5 In most settings, however, health workers continue
to wait and test only at 18 months with HIV antibody tests. Initiation of co-trimoxazole prophylaxis is
particularly important in these settings as it affords the possibility of delaying the onset of OIs in HIVinfected infants prior to confirmatory diagnosis and subsequent initiation of ART.
HIV antibody testing conducted early in life can confirm HIV exposure as it detects persisting maternal
HIV antibody in the infant. Antibody testing is therefore useful in identifying infants not previously
known to be HIV exposed so that they too may benefit from the protection from OIs afforded by
co-trimoxazole prophylaxis. It is also useful in identifying HIV-uninfected and -unexposed infants.6
HIV antibody testing is therefore an important intervention to screen infants and young children for HIV

II
exposure in high HIV-burden settings, so as to identify those in need of co-trimoxazole prophylaxis
and HIV viral testing.
Of the 2 million children infected with HIV in 2007, the vast majority of those estimated to be in need
of ART were not receiving it,7 despite the UNICEF/Joint United Nations Programme on HIV/AIDS
(UNAIDS) target of providing ART, co-trimoxazole prophylaxis or both to 80% of children in need by
2010.7 While access to ART remains limited for children, use of co-trimoxazole prophylaxis may be
lifesaving.

C. Ac c e s s to c o -t r i m oxa zo l e p r o p hy l a x i s fo r i n f a n t s a n d
children
Data regarding the current need for and uptake of co-trimoxazole prophylaxis globally for both HIVexposed and -infected infants are difficult to obtain as many countries have only recently begun to
collect and report data on this intervention. UNICEF and WHO, however, are working with countries to
develop systems that support more accurate reporting on this in the future. Data regarding initiation
of co-trimoxazole prophylaxis in HIV-exposed infants were first reported in 2007. Approximately 1.4
million women with HIV gave birth in low- and middle-income countries and all of these children
should have been initiated on co-trimoxazole prophylaxis by four to six weeks of age. However, 2008
estimates reveal that only about 8% of infants needing co-trimoxazole prophylaxis had been started
on it by two months of age.4

III

I I I . R ATI O N A LE A N D R ECO M M E N DATI O N S

A . R a t i o n a l e
Co-trimoxazole is a combination of two antibiotics sulfamethoxazole and trimethoprim. It is widely
available in a number of forms and is known by several brand names. The most common use of cotrimoxazole is for the first-line management of acute respiratory infections (ARI) in children, but it is
also used to treat diarrhoea and PCP, as well as infections of the urinary tract and middle ear.
To prevent PCP in HIV-infected individuals, co-trimoxazole has been the standard of care in highincome countries for many years, based on a number of studies that have demonstrated its benefits,
primarily in HIV-infected adults.8 There were initial concerns by some policy-makers and MCH experts
that widespread use of co-trimoxazole as prophylaxis would undermine its efficacy in the management
of ARI, and would lead to problems of antibiotic resistance in common pathogens. More recent studies
have not substantiated such fears and have demonstrated population-level benefit. These studies are
discussed in the WHO co-trimoxazole prophylaxis guidelines.8
It has also been recognized that co-trimoxazole prophylaxis provides benefits beyond the prevention of
PCP. A randomized controlled trial among HIV-infected children in Zambia demonstrated that mortality
was reduced by half and the number of hospital admissions was significantly reduced among children
using co-trimoxazole.9 These findings, along with other evidence of efficacy and cost-effectiveness,
as well as fewer deaths due to ARI in HIV-infected infants under the age of six months,10,11 have
highlighted the benefits of co-trimoxazole prophylaxis for infants and children with HIV.
Co-trimoxazole prophylaxis also protects against episodes of malaria (estimated 99.5% protection
from pooled data).12 Mortality from malaria in HIV-infected children and adults is also reduced if they
are on co-trimoxazole (pooled data estimates RR 0.62 [0.510.74] comparing HIV-infected persons
on co-trimoxazole with HIV-infected subjects not on co-trimoxazole).13 A similar reduction in mortality
was seen in a subgroup of children below five years of age (RR 0.68, 0.510.91) in the Children with
HIV Antibiotic Prophylaxis (CHAP) study from Zambia.9
In addition to the clinical benefits of co-trimoxazole prophylaxis for the prevention of OIs associated
with HIV disease, other benefits include the following:14
it can be delivered to children at levels of the heath-care system that cannot yet offer ART.
it can be provided through a family-based approach as the benefits of co-trimoxazole prophylaxis
are important for both adults and children.
it encourages drug adherence behaviours before initiation of ART.
it can reduce the burden of communicable diseases in the index case and other family
members, and;
it can prevent malaria.
Finally, co-trimoxazole prophylaxis is a low-cost intervention, with a unit cost of only about
US$ 0.03 per child per day, or about US$ 10/year.15

III
B . W H O r e c o m m e n d a t i o n s
The WHO guidelines provide recommendations and related evidence for the use of co-trimoxazole
prophylaxis.8
HIV-exposed infants and children: In settings with a high prevalence of HIV, high infant
mortality due to infectious diseases and limited health-care infrastructure, WHO recommends cotrimoxazole prophylaxis for all HIV-exposed infants and children, starting at four to six weeks
after birth and maintained until at least six weeks after cessation of risk of HIV transmission and
definitive exclusion of HIV infection in infants.
HIV-infected infants and children:
>> For infants with confirmed HIV infection who are less than one year of age, cotrimoxazole prophylaxis is indicated regardless of the CD4 percentage or clinical status.
>> For infants and children one through four years of age, initiation of co-trimoxazole
prophylaxis is recommended if the child has WHO clinical stages 2, 3 or 4, regardless of
CD4 percentage, or if the child has a CD4 percentage <25 at any WHO stage. Countries
are advised that they may choose to institute universal co-trimoxazole prophylaxis for all
HIV-infected infants and children irrespective of the clinical or immunological stage.
>> For children 5 years of age or older, WHOs adult guidelines should be followed.8
Children with a history of treated PCP should be administered the same regimen of co-trimoxazole
prophylaxis as that recommended for primary prevention.
More detailed recommendations from WHO on eligibility, formulations and dosages, initiation of
secondary co-trimoxazole prophylaxis, and discontinuation of co-trimoxazole prophylaxis can be
found in Appendix A.8

C. Ad h e r e n c e
Adherence may be challenging when co-trimoxazole prophylaxis is given to very small infants, and in
infants who need to take co-trimoxazole prophylaxis for long periods of time. Ensuring good adherence
is an ongoing process that begins at the first clinical encounter and continues at every subsequent
interaction with the caregiver. Adequate initial and ongoing counselling is critical to achieving good
adherence. Initial counselling can help caregivers identify factors that may interfere with adherence,
while ongoing counselling both reinforces positive trends and allows for the detection of emerging
issues. Helping caregivers develop cues based on daily life activities that trigger medication
administration is a particularly useful technique for improving long-term adherence.
Emphasis on adherence training and implementation of adherence strategies need to be as strong in
community-based programmes as in clinical programmes. Community-based organizations (CBOs),
existing home-based care services and womens groups will require comprehensive training in
treatment literacy and adherence support.
Imperfect adherence to co-trimoxazole prophylaxis should not, however, be a reason to discontinue
it, as prevention efficacy is maintained even with thrice-weekly dosing. While the benefits may be
reduced with less-than-perfect adherence, it is likely that there will still be some benefit.

III
Improving adherence through once-daily dosing
Baylor International Pediatric AIDS Initiative (BIPAI) initiated once-daily dosing of co-trimoxazole
prophylaxis at its Center of Excellence in Gaborone, Botswana. Families have reported that this
has made adherence to co-trimoxazole prophylaxis easier as they no longer have to think about
which days of the week they need to administer co-trimoxazole prophylaxis to their infants.

D. D i s c o n t i n u a t i o n o f c o -t r i m oxa zo l e p r o p hy l a x i s
Co-trimoxazole prophylaxis may need to be discontinued in the event of an adverse drug reaction.
Although severe reactions to co-trimoxazole are uncommon, these may include extensive exfoliative
rash, StevensJohnson syndrome, or severe anaemia or pancytopenia.
Guardians and caregivers should be provided with verbal or written information on the potential adverse
effects, and advised to stop the drug and report to their nearest health facility if co-trimoxazole-related
adverse events are suspected. Current evidence is insufficient to recommend discontinuation of cotrimoxazole prophylaxis once the child is stable on effective ART.

I V. CH A LLE N G E S

IV

Several barriers have been identified to effective, broad national scale up of co-trimoxazole prophylaxis.
These include the following:
1.

Inadequate policies, operational guidelines and plans for co-trimoxazole prophylaxis:

By 2008, while most resource-limited countries had integrated co-trimoxazole prophylaxis into
national policy documents on PMTCT, ART and maternal, newborn and child health (MNCH),
there remained a lack of sufficiently detailed operational guidance to advise national programme
managers on exactly how co-trimoxazole prophylaxis is to be scaled up at the health-service
level.

2.

Limited integration of PMTCT services within MCH and ART programmes, and weak
links between these programmes and other child health services: PMTCT services are
the crucial link to timely identification of HIV-exposed infants who are eligible for co-trimoxazole
prophylaxis. However, because of the traditional practice of vertical programming, PMTCT
services are often not sufficiently integrated into MCH programmes, making it difficult to monitor
mothers and infants.16 Mothers and infants are often seen separately at clinics, even when they
are both in need of HIV services, bringing other factors such as time, transportation and cost into
play as additional barriers.

3.

Missed opportunities to identify infants and children in need of co-trimoxazole

prophylaxis and other HIV services: Many infants born to HIV-infected mothers do not receive
appropriate interventions, including co-trimoxazole prophylaxis, because they are not identified
as being HIV-exposed. Such missed opportunities are the result of a lack of appropriate training
of health-care workers, limited use of clinic tools such as child health cards documenting HIV
exposure status, or absence of systems whereby health workers providing care to children make
HIV assessment a routine part of their initial interaction with the child. In addition, many other
children showing early signs and symptoms of HIV infection remain untested for HIV infection
because of lack of training or absence of facilitative policies. Frequently, communities have also
not been sufficiently informed or sensitized to identify HIV-exposed infants and children so that
they can be referred to care.

4.

Other barriers: Other constraints that limit health workers ability to implement co-trimoxazole
prophylaxis include limited policy support for lower-level workers to dispense co-trimoxazole
prophylaxis, insufficient training on the importance of co-trimoxazole prophylaxis of those
allowed to prescribe and dispense it, and failure to include co-trimoxazole prophylaxis in training
materials for HIV care and treatment.
In terms of supplies, barriers include insufficient quantities of co-trimoxazole made available for
prophylaxis, a lack of clarity on sharing of supplies across programmes, inadequate procurement
policies and procedures, and problems with storage and distribution.

V. K E Y S TR ATEG I E S FO R SCA LI N G U P
Six key strategies are essential for scaling up co-trimoxazole prophylaxis for HIV-exposed and -infected
children.
1.

Ensure government leadership, ownership and accountability for the provision of cotrimoxazole prophylaxis to HIV-exposed and -infected infants and children. These are
demonstrated by the formulation of supportive policies, setting of national targets and development
of budgeted national plans for scaling up, directed towards reaching all children in need.

2.

Integrate co-trimoxazole prophylaxis for children into existing services. These include
services such as HIV and MNCH, and decentralized delivery to the lowest appropriate, effective
and feasible level of the health-care system.

3.

Maximize the use of all available entry points to ensure timely initiation of cotrimoxazole prophylaxis. This can be facilitated through the use of child health cards with
HIV-specific information as well as through PITC to identify HIV-exposed and HIV-infected infants
and children as part of outreach services, immunization and home-based care.

4.

Develop reliable national- and district-level procurement and supply management

mechanisms. These ensure a consistent supply of co-trimoxazole for prophylaxis of infants and
children in need.

5.

Strengthen community-based capacity to identify HIV-exposed and -infected infants

and children. This is necessary for referral to testing, care (including initiation and continuation
of co-trimoxazole prophylaxis) and treatment.

6.

Strengthen monitoring and evaluation systems. Such systems support the provision of
high-quality care for children who are exposed to or infected with HIV, including the provision of
co-trimoxazole prophylaxis.

The action steps needed to incorporate each of these strategies into national programmes are outlined
below.

Strategy 1
Ensure government leadership, ownership and accountability for provision of co-trimoxazole
prophylaxis for HIV-exposed and -infected infants and children, demonstrated by the formulation
of supportive policies, setting of national targets and development of budgeted national plans
for scaling up co-trimoxazole prophylaxis so as to reach all children in need.
Effective leadership, ownership, programme management and coordination capacity are needed at
the national and subnational levels (such as districts) to promote and support the scaling up of cotrimoxazole prophylaxis for eligible children.

V
Relevant actions
1.1

Conduct a situational analysis

An initial rapid, brief but systematic situational analysis should be performed1 to assess current levels
of programming. This should include key health system bottlenecks to provision of co-trimoxazole
prophylaxis so that national MNCH and/or HIV strategic plans can revised and/or adapted to better
address the provision of co-trimoxazole prophylaxis.
A tool for such an assessment can be found in Appendix E. Key elements to be assessed in the
situational analysis include the following:
Epidemiological profile (e.g. number of HIV-infected pregnant women giving birth annually, number
of children exposed to or infected by HIV, proportion of eligible children currently receiving cotrimoxazole prophylaxis);
Health system capacity to provide co-trimoxazole for prophylaxis (e.g. level of health facility able
to provide co-trimoxazole prophylaxis, training provided, level of decentralization of PMTCT and
other HIV care delivery);
National policies and guidelines that refer to co-trimoxazole prophylaxis (e.g. indications for use of cotrimoxazole prophylaxis in national policies and guidelines, including who can prescribe and dispense);
Operational plans to complement policies and guidelines (e.g. existence of a paediatric HIV
care and treatment plan, and inclusion of co-trimoxazole prophylaxis in the plan, a system for
identifying children requiring co-trimoxazole prophylaxis, provision of training, and development
and distribution of job aids for co-trimoxazole prophylaxis);
Financial, logistical and human resources available to implement co-trimoxazole prophylaxis; and
Monitoring and evaluation system (e.g. use of national-level indicators for co-trimoxazole prophylaxis,
data analysis and quality improvement activities focused on co-trimoxazole prophylaxis).
1.2

Establish co-trimoxazole prophylaxis-related targets

Time-bound targets are essential to scale up interventions as learned from recent experience (i.e.
WHOs 3 by 5 Initiative, the US Presidents Emergency Plan for AIDS Relief [PEPFARs] 2-7-10 goals)
because they set a tone of urgency and motivate national programme managers to take action.
Population-based or geographically based targets can also be used locally to drive planning: for
example, co-trimoxazole prophylaxis targets for urban areas will probably differ from the targets
for rural areas. Setting district-level targets is also important, since it assigns expectations and
accountability, and assists in coordinating supportive technical assistance, including targeted training
for health-care providers and ensuring that appropriate quantities of supplies reach the sites in need.
Decisions regarding district- and subdistrict-level targets will need to be based on considerations
of local capacity to prescribe co-trimoxazole prophylaxis, particularly in areas where health centres
do not have a medical doctor or officer on the staff, and nurses or other health-care workers do not
have the capacity to prescribe and dispense co-trimoxazole prophylaxis. Establishing targets can
also be useful for leveraging and mobilizing resources as they provide a quantifiable and measurable
understanding of the countrys expectations for scaling up.
27 Ideally, information regarding usage of co-trimoxazole prophylaxis should be collected as part of existing situational
analyses addressing HIV care and MCH to expedite implementation and maximize the use of valuable resources.

10

V
1.3

Ensure that existing management and coordination structures focus on the needs
of children affected by HIV (exposed and infected) and address co-trimoxazole
prophylaxis for children.

The relevant management and coordinating body should:

Include co-trimoxazole prophylaxis for children in national scale-up plans for PMTCT of HIV as well
as those for care and treatment.
Develop appropriate policies to facilitate the initiation of co-trimoxazole prophylaxis for children.
Examples of such policies include but are not limited to:
>> PITC recommended for sick children in sites likely to have large numbers of children who have
HIV such as paediatric wards, tuberculosis units and malnutrition clinics, as well as all children
of adults receiving ART to identify those eligible for co-trimoxazole prophylaxis;
>> using mechanisms to communicate a childs HIV exposure or infection status both within
facilities as well as between sites, such as with child health cards on which HIV exposure status
is documented to facilitate initiation of co-trimoxazole prophylaxis;
>> utilizing well-baby services such as clinics providing immunization or growth monitoring to
routinely assess infants and young children for HIV-exposure status;
>> providing co-trimoxazole prophylaxis and other paediatric HIV services free of user charges for
children;
>> revising national scopes of practice to permit additional types of health workers to prescribe
and dispense co-trimoxazole prophylaxis for children;
>> using community case management programmes addressing pneumonia, malaria and diarrhoea
to identify HIV-exposed children in need of co-trimoxazole prophylaxis; and
>> using community-based HIV testing and counselling programmes to identify exposed and
infected infants and children in need of co-trimoxazole prophylaxis.
These policies should be incorporated into site preparation processes, standard operating procedures
and personnel expectations, and actively disseminated so that they are implemented.
Review and adapt existing guidelines pertinent to delivering co-trimoxazole prophylaxis to children.
WHO has developed guidelines specifically focused on co-trimoxazole prophylaxis for adults and
children, which can be adapted for national use.8 Other guidelines developed by WHO17 also refer
to co-trimoxazole prophylaxis for children and may be of use in revising national guidelines on the
following:
>> PITC and infant diagnosis18
>> services for PMTCT2
>> ART for children19
>> patient monitoring guidelines19
>> infant and young child feeding20
>> tuberculosis21
>> malaria 22,23
>> Integrated Management of Childhood Illness (IMCI) 24
11

V
Where co-trimoxazole is currently recommended, national management guidelines for ARI, malaria,
diarrhoea and dysentery may need to be reviewed and aligned to incorporate this.
Develop dissemination and communication strategies/materials to raise awareness of revised
policies and guidelines. Ensure that the reach of communication materials extends to community
and other local care providers.
Coordinate the training of health-care workers. As governments move to decentralize the delivery
of paediatric HIV care and treatment including co-trimoxazole prophylaxis, there will be a need
for coordinated national training. District-level coordination is essential to ensure that training is
applied consistently across sites and reaches all the providers who need it. Supportive supervision
is also essential to ensure that the knowledge and skills obtained during training sessions are
effectively translated into their day-to-day work.
1.4

Ensure district-level leadership, ownership and accountability for the scale up of cotrimoxazole prophylaxis.

To ensure effective increases in the uptake of co-trimoxazole prophylaxis, it is essential that critical
government functions extend beyond the national level to much lower levels of the government
such as the district level. District-level managers should be involved in district-level planning and
implementation of the national policy on co-trimoxazole prophylaxis, coordination of local training,
setting of site-specific targets, provision of supportive supervision, and monitoring of the quality of
care delivered.
Integrate commodity needs specific to co-trimoxazole prophylaxis for infants and children who
are exposed to or have HIV into national procurement and supply management systems (see the
section on supply management [Strategy 4]).
Integrate indicators on co-trimoxazole prophylaxis for children into monitoring and evaluation
systems (see the section on monitoring and evaluation [Strategy 6]).

Strategy 2
Integrate co-trimoxazole prophylaxis for children into existing services such as HIV and MNCH,
and decentralize delivery to the lowest appropriate and feasible level of the health-care system.
Decentralized delivery of co-trimoxazole prophylaxis and other HIV care through an integrated package
of services for the child and family offers several advantages:
It delivers care for all family members at the same time and place;
It minimizes costly and time-consuming transport to and from tertiary centres;
It facilitates the continuity of care between the home, community and health centre; and
It maximizes efforts to improve adherence and overcome barriers to long-term engagement in care.

12

V
Increasing the provision of co-trimoxazole prophylaxis in five districts in Rwanda:
the impact of district planning, training and supportive supervision
Following a district action planning exercise as part of the National Conference on Paediatric
HIV in Rwanda in 2007, BASICS has provided support to five selected districts to improve the
performance of PMTCT and paediatric HIV services. The provision of co-trimoxazole prophylaxis
to HIV-exposed and -infected children has been integrated into the national Integrated
Management of Neonatal and Childhood Illness (IMNCI)HIVBirth Spacing training module
in 25 districts and in the district paediatric HIV action plans in five districts in Rwanda.A cotrimoxazole prophylaxis indicator has been integrated into the IMNCI supervision and monitoring
tool for the districts. In a review of 16 health facilities in five districts after implementation of
the action plan training for paediatric HIV, the number of children receiving co-trimoxazole
prophylaxis increased from 522 in September 2007 to 715 by March 2008. This indicated a 36%
increase in the number of children who received co-trimoxazole prophylaxis following training
of health-care workers to identify HIV-exposed and -infected children and place them on cotrimoxazole prophylaxi. Source: Mary Lyn Field-Nguer, BASICS

Relevant actions
2.1

Integrate initiation of co-trimoxazole prophylaxis into existing MNCH programmes.

Existing MNCH programmes include specific services such as immunization, which are well established,
well attended and have high penetration into the communities being targeted. MNCH clinics therefore
provide the greatest potential for expanding services for co-trimoxazole prophylaxis, as virtually all HIVexposed infants will be there during their first year of life. Ministries of health interested in increasing
the coverage and uptake of co-trimoxazole prophylaxis should concentrate initial efforts on ensuring
that MNCH settings are able to identify HIV-exposed children, start co-trimoxazole prophylaxis and
refer for other essential HIV services.
At present, however, these programmes often do not address the HIV-related needs of children such
as co-trimoxazole prophylaxis. Health-care workers can more effectively recognize when infants and
children need HIV testing and co-trimoxazole prophylaxis if the child health card includes information
related to services for PMTCT. In addition to recognizing HIV-exposed children who appear otherwise
well, health-care workers should also be trained and directed to ensure that HIV infection is considered
in the diagnosis of infants and young children who present with an illness to child health services.
Acute care services for infants and children must be able to provide age-appropriate HIV testing and
counselling and initiate co-trimoxazole prophylaxis (see also 3.1).

13

V
Approach to HIV diagnosis, care, support and treatment through Integrated
Management of Childhood Illness (IMCI)
Several countries (Botswana, Ethiopia, Kenya, Lesotho, Namibia, Rwanda, South Africa,
Swaziland, Uganda, Zambia and Zimbabwe) have adapted their IMCI materials to include HIV
and AIDS. The IMCI HIV guidelines are similar to the existing syndromic guidelines for common
childhood illnesses, since they provide health-care workers with a checklist to determine
whether a child might be either exposed to or infected with HIV. The first question during the
child assessment is whether the mother received an HIV test during antenatal care (ANC).
Depending on the answer received and the presence or absence of other symptoms including
pneumonia, persistent diarrhoea or severe malnutrition, the health-care worker can classify
the child into different HIV exposure and infection categories, and determine the next steps to
follow in the childs care plan, including initiation of co-trimoxazole prophylaxis.25

Swaziland: Improving early postnatal care

Early postnatal care is the most neglected area of maternal and newborn health (MNH) in
developing countries. It provides an opportunity to identify and address problems, including
infection with HIV in postpartum women and exposure of their newborn babies. In Swaziland,
one of the countries with the highest HIV prevalence in the world (39% among pregnant women
in 2007), BASICS and partners implemented the integration of focused, quality postnatal care
for all postpartum women and their newborn babies. One of the objectives of this intervention
was to improve the follow up and care of HIV-positive mothers and their exposed babies, who
were being lost to care after being identified by the national PMTCT programme during ANC.
This facility-based programme included training of health staff involved in MNH care, facilitation
of organizational changes needed to provide the new postnatal care services, and supportive
supervision of personnel providing the care. An evaluation carried out one year after initiation
of the service showed a significant increase in the proportion of both HIV-positive postpartum
women and their infants started on co-trimoxazole prophylaxis as a result of counselling during
the early postnatal visits (within one week of birth), from 47% to 65%, and from 13% to 37%,
respectively (P<0.01). Providers also confirmed that HIV-positive postpartum women received
the relevant or appropriate follow-up care and treatment.

14

Percent of mothers & babies

receiving cotrimoxazole
during PP period

V
Cotrimoxazole prophylaxis in HIV positive mothers
and their exposed infants
100

***p<0.01

Baseline 2006

80
60

Endline 2007

65
47

37

40
20

13
Mother***

Baby***

Source: Mazia G et al. Integrating quality postnatal care into PMTCT in Swaziland. Global Public Health Journal, 2009 (in press).26

2.2

Decentralize delivery of co-trimoxazole prophylaxis to the lowest levels of the health

system.

Health-care workers with minimal clinical background or experience in HIV care and treatment can
effectively deliver co-trimoxazole prophylaxis. Community leaders and health-care workers need to
understand that co-trimoxazole preventive treatment is a low-cost and easy-to-deliver intervention
that can dramatically reduce morbidity and mortality. By using community-based channels or health
outreach services, as well as local pharmacies and drug vendors, co-trimoxazole prophylaxis can be
provided much closer to where children who need it live.
Decentralization of co-trimoxazole prophylaxis requires district-level planning. District-level managers
will need to be involved in implementation of the national policy for co-trimoxazole prophylaxis,
development of site-specific targets, coordination of local training, provision of supportive supervision
and ensuring the quality of care delivered.

Strategy 3
Maximize the use of all available entry points to ensure timely initiation of co-trimoxazole prophylaxis.
This will be facilitated through the use of PITC to identify HIV-exposed and -infected infants and
children, as well as through outreach services including immunization and home-based care.
A.

Optimize the follow up of known HIV-exposed infants identified through services

for PMTCT.

Although many countries are moving towards national coverage of services for PMTCT, most children
born to women known to be living with HIV are not being systematically monitored and followed up
during the postpartum period. HIV-exposed children must be followed up to minimize the risk of
postpartum HIV transmission and improve infant health outcomes through provision of co-trimoxazole
prophylaxis and other essential services including ARV prophylaxis for the infant, early infant diagnosis,
and infant-feeding counselling and support.

15

V
Relevant actions
3.1

Ensure the availability of policy and technical guidance supporting the follow up of
infants known to be exposed to HIV through their connection to PMTCT services so
that co-trimoxazole prophylaxis may be initiated and they may receive other essential
interventions in a timely manner.

3.2

Document information on the childs HIV exposure/infection status including receipt

of PMTCT services by the mother and child on MNCH cards to facilitate initiation of
co-trimoxazole prophylaxis for eligible infants.

Health-care workers providing care to either the mother or the infant can use health cards with HIV
exposure and infection status documented on it to facilitate initiation of HIV-related follow up of the
infant. Health cards, in addition to carrying information such as height, weight, immunization history,
should note whether the child is known to be HIV exposed or infected, and can contain some or all of
the following information:
HIV status of the mother;
ARVs provided to the mother and/or infant;
HIV testing status of the infant; and
whether co-trimoxazole prophylaxis was initiated for the mother or infant.
Lesotho: Optimizing follow up on HIV-exposed infants
Lesothos example of creating a stamp that can be stamped at birth into the childs bukana
(portable health record) is illustrative. The stamp is designed to be applied to the bukanas of all
children born to mothers known to be HIV-infected. It is the size of one of the bukanas small
pages, and includes a prompt to the paediatric care provider to ensure that the child is initiated
on co-trimoxazole prophylaxis at four to six weeks after birth or as soon thereafter as the
childs first encounter takes place. The stamp may even be placed in a bukana to be given to a
child after birth, providing a critical opportunity for the maternal care provider to ensure, at the
moment the mother tests positive, that the newborn infant will be identified as HIV exposed. All
of this helps link the need for co-trimoxazole prophylaxis from the prenatal or delivery setting to
the initial clinical setting in which the child is cared for even when these are space- and timeseparated, as is commonly the case. Lesotho has shown a strong commitment to this concern
at the central level by incorporating the information on the stamp into a permanent page in the
new bukana.
Source: Michael A. Tolle, Lineo Thahane, Tony Garcia-Pratts, Baylor International Pediatric AIDS Initiative (BIPAI)

This approach has also been successfully used in several other countries, including Zambia and
Zimbabwe. Health-care workers are made aware by looking at either the mothers or childs health
card that the child has been exposed to HIV and are prompted to ensure that important interventions
including provision of co-trimoxazole prophylaxis and early diagnostic testing are implemented. In
addition, this ensures that both the mother and the child are followed more carefully to monitor for any
signs suggestive of HIV infection. The health-care worker who provides the first set of immunizations
16

V
to the child at six weeks of age is ideally positioned to review the childs HIV status and provide the
necessary HIV-related services such as co-trimoxazole prophylaxis or HIV testing, or refer the child
for it. For this mechanism to work, at a minimum, the following must be in place.
Information on services for PMTCT, including the childs HIV exposure status, must be documented
on the childs health card and included on the mothers health card (Figure 1).
Childrens health cards must be distributed in a timely fashion at or around delivery. Some countries
now provide the pregnant woman living with HIV with a child health card documenting HIV exposure
status at the time she receives her HIV result.
Information on the child health card or motherbaby booklet must be standardized nationally and
follow nationally agreed-upon guidelines.
Health-care workers must be oriented to and vested in the utility of this information.
Measures must be taken to ensure patient confidentiality.
Health-care workers in ANC should also sensitize pregnant women with HIV to inform the childs healthcare provider of the childs exposure status so that he/she can receive the necessary interventions at
the six-week clinic visit.
Figure 1. PMTCT panel from child health card used in Zambia

HILDRENS CLINIC CARD

PMTCT

IMMUNISATION RECORD

MUNISATION against Tuberculosis (TB)

G (at birth)

scar after 12 weeks,

at dose. Unless symptomatic HIV

V0

(at birth to 13 days)

V1

Date .......................................

(at 6 weeks)

DPT-HepB-Hib 1 (at 6 weeks)

Test by:

 Babies born to HIV positive mothers have special feeding needs

ast 4 weeks after OPV 1)

DPT-HepB-Hib 2

(at least 4 weeks after DPT-HepB-Hib1)

DPT-HepB-Hib 3

ast 4 weeks after OPV 2)

(at least 4 weeks after DPT-HepB-Hib 2)
........................................... Date .....................................................

V4

(at 9 months, only if OPV 0

was not given)

Measles

osage:

VITAMIN A SUPPLEMENTATION

Date

0-5 months, 50,000 IU only if not breastfed;

6-11 months,100,000 IU;
12-59 months, 200,000 IU every six months
Date
Dosage
Dosage

Rapid Test

12
12

Rapid Test

18
12

Discuss with a health worker.

IF THE CHILD HAS DIARRHOEA

 If the child is still on breast milk, continue breast feeding.

After each loose stool, do the following:

 Give ORS
 Give extra fluids
 Continue to feed the child.

IGA
6 Weeks 2 Months

4M

5M

6M

7M

10M 12M

15M

18M

24M

3M

Note: (dilute 1 sachet of ORS in 1 litre of boiled cooled water)

Go immediately to the nearest Health Centre.

Cotrimoxazole
Follow up time

.......................................... Date ....................................................

Date
Date

6
52

Follow up time

(at 9 months, or soon after.

Unless symptomatic HIV)

OTHER IMMUNISATIONS

PCR

NR

MGA

.................................... Date .....................................................

V3

DATE

Date ..............................................

V2

IMPORTANT:

 All infants and young children should be breastfed exclusively fo

the first six months of life and continue to breastfeed up to two

years and beyond with adequate complementary feeding from si
months of age unless medically indicated.

Date ..............................

Date ..............................

UNISATION against Polio (OPV), Diphtheria, Whooping

gh, Tetanus, Hib, Hepatitis B, Meningitis, Pneumonia
T-HepB-Hib) & Measles

....................................

CNE

MSU

CE

9M

8M

Date baby referred for ART............/.........../..........

Date initiated on ART............../.............../.............

The child may have Pneumonia, Go immediately to the neare

Age at initiation of ART.........................................

MONITORING OF INFANT AND YOUNG CHILD FEEDING

Follow up time

Birth 6 Days 1M

6W

2M

3M

4M

5M

7M

8M

Health Centre.

DISCUSS

6M

Infant feeding code

Follow up time

PNEUMONIA

If a child has a cough with:

 Fast Breathing
 Difficulties in breathing
 Difficulties in breast-feeding

Cotrimoxazole

9M 10M 11M 12M 15M 18M 24M

Infant feeding code







Breastfeeding
Complementary feeding
Immunisation
Vitamin A supplementation
Family planning

Feeding Code:
1)

Source: Ministry of Health, Government of Zambia

Exclusive breast feeding (in the first 6 months, breast-feeding only, no water,
no other fluids except medicines indicated by medical personnel)

MOTHER

te Vit. A given to the mother

2)

Exclusive Alternative Infant Formula

3)

Animal Milk

4)

Mixed feeding (breast milk and other foods)

5)

Continued breast feeding after six months in addition to other foods

6)

Milk based feed after six months in addition to other foods

17







Feeding during and after illness

Safe food and drinking water
Treatment of diarrhoea
HIV/AIDS
Malaria

V
B.

Identify infants and children who have HIV and are eligible for co-trimoxazole
prophylaxis.

The vast majority of infants who have HIV are currently not identified through PMTCT or routine MCH
services but are diagnosed when they present to inpatient and outpatient health services with signs
and symptoms suggestive of HIV infection. A large number of children who have HIV have been
identified through PITC in acute care settings in many countries including Cameroon, Uganda, Zambia
and others.
For example, a study on the referral patterns of HIV care and treatment for children in
Malawi found that only 1% of the children referred for ART come from services for PMTC.
The vast majority (80%) are identified as a result of HIV testing conducted in childrens wards or
nutritional rehabilitation units (Figure 2).27 These children should usually be immediately initiated on
ART and co-trimoxazole prophylaxis.
Figure 2. Referral sources for antiretroviral therapy for children in Malawi
Wards, nutritional
rehabilitation units (80%)

Follow up of prevention
of mother-to-child
transmission (1%)

Antiretroviral
therapy clinic for children

Clinic of person
receiving ART (1%)

Clinic for children

younger than 5 years (18%)

Source: Report of a country-wide survey of HIV/AIDS services in Malawi for the year 2006.27

Relevant actions
3.3

Implement PITC at sites likely to yield a high volume of positive HIV test results to
identify infants and children in need of co-trimoxazole prophylaxis and other HIV
services.

Protocols and systems should be established for routinely recommending HIV testing for hospitalized
children, those attending malnutrition clinics, those with TB and those younger than five years with
other signs and symptoms suggestive of HIV infection such as severe pneumonia, severe persistent
diarrhoea, ear discharge or very low weight for age. Infants and children identified as exposed to or
infected with HIV should be promptly initiated on co-trimoxazole prophylaxis and ART, if indicated.

18

V
Use of PITC to identify HIV-infected infants and children
In all of its African sites, BIPAI promotes PITC in multiple clinical settings where children are
cared for, particularly inpatient wards and outpatient clinics. In Lesotho, BIPAI helped to
institute PITC of all children admitted to the inpatient paediatric ward at the national hospital in
Maseru. This has helped identify HIV-exposed and HIV-infected children who would otherwise
have escaped detection, and ensure their enrolment in HIV/AIDS care, treatment and support
services, including the administration of co-trimoxazole prophylaxis.
Source: Michael A. Tolle, Baylor International Pediatric AIDS Initiative (BIPAI)

3.4

Institutionalize a family-centred approach and secure HIV testing for all additional
family members once an index case is identified.

If one family member is identified as having HIV infection, it is very important to recommend HIV
testing and counselling for the other family members. In many families, more than one person has
HIV. Programmes can help ensure that all family members are tested by requiring information on all
other family members on a persons health card, including information on HIV testing. Ensure cotrimoxazole prophylaxis for mother and baby/child as indicated.
3.5

Use approaches such as the IMCI and Integrated Management of Adolescent and
Adult Illness (IMAI) to identify infants and children at peripheral sites in need of HIV
testing and co-trimoxazole prophylaxis.

IMCI has a modified algorithm for assessing children presenting to primary health facilities.25 The
algorithm is designed to optimize management of infants and children exposed to or infected with HIV.
For the HIV-exposed child, health-care workers are guided to ensure that the child receives appropriate
interventions including co-trimoxazole prophylaxis and early testing. First-level health-care workers
should be trained to improve their ability to recognize a child who may have HIV (as in the HIV-adapted
IMCI approach). This involves training health workers including private sector pharmacists and drug
sellers to recognize signs and symptoms that are common among children who have HIV, and provide
basic care and appropriate referrals. The generic IMCI HIV algorithm is given in Appendix B.
3.6

Use community health workers to facilitate entry to diagnosis and care services.

Ensure that the community health workers providing community-based case management or treatment
for common childhood infections such as diarrhoea, pneumonia, malaria and fever are able to recognize
the signs of HIV infection, refer for HIV testing, and provide co-trimoxazole prophylaxis as required.

Strategy 4
Develop reliable national- and district-level procurement and supply management mechanisms
that ensure a consistent supply of co-trimoxazole for paediatric prophylaxis needs.
In the context of HIV care and treatment for children, a well-functioning supply system is critically
important to ensure that children who need commodities and other material resources for routine HIV
care (including medicines to prevent and treat common OIs) can access them when and where they
need them.
19

V
As for all health-care commodities, the steps for establishing a functioning supply management
system can be structured according to the processes in the supply cycle: selection, procurement
(including quantification), distribution (including inventory management), use, and the organizational
and managerial functions underpinning them.

Relevant actions
4.1

Ensure that supply management is appropriately coordinated among supply

stakeholders and also linked to the overall implementation plan. Where there is a
working group on procurement and supply management of drugs for HIV, integrate
co-trimoxazole prophylaxis for infants and children into the existing mechanism.

4.2

Develop estimates of need and determine additional resource requirements for cotrimoxazole products taking into account:
Requirements for HIV and non-HIV use, and current national and partner contributions to both
National guideline recommendations for starting and continuing co-trimoxazole prophylaxis
in infants and children
Formulation and dosage requirements for each age/weight group
Co-trimoxazole prophylaxis targets disaggregated by age/weight group
Other providers such as faith-based organizations, implementing partners and accredited
private providers providing services on behalf of the government
Areas where interruptions in co-trimoxazole supply for non-HIV use commonly occur. Identify
requirements and funding to fill the gap to avoid depleting stocks ordered for co-trimoxazole
prophylaxis.

For determination of budget requirements and potential procurement sources, the following sources
may be consulted:
1. International drug indicator price guide 28 (Management Sciences for Health [MSH]), which provides
an indication of pharmaceutical prices on the international market, and
2. Global Price Reporting Mechanism (WHO).29
4.3

Select products containing co-trimoxazole and confirm registration status.

Select appropriate formulations (syrup, paediatric tablets or adult tablets), minimizing, where
possible, the number of products that will need to be procured, stored and distributed.
Determine if soluble, scored tablets and/or products that are formulated to be cut will be
needed.
Confirm that the products are registered in-country and determine if the essential medicines
list (EML) will need to be revised to include co-trimoxazole for prophylaxis.
Determine criteria to assure the quality of co-trimoxazole products (e.g. those manufactured
according to Good Manufacturing Practices [GMP], or have undergone post-test evaluation).

20

V
4.4

Plan for procurement and distribution.

Foster integration of co-trimoxazole supply systems for HIV and non-HIV use where possible
by building on what exists and strengthen capacity where it is lacking.
Define the procurement strategy for co-trimoxazole prophylaxis. Consider the availability of
donations, and whether procurement for co-trimoxazole prophylaxis can be integrated into
existing procurement methods, for example, for essential medicines.
Consider sourcing and pricing (see resources listed above under section 4.2).
Regularly update procurement and distribution plans to match revised co-trimoxazole
prophylaxis targets and distribution at new sites.
Determine the distribution mechanisms for reaching sites and ensure that the supply of cotrimoxazole reaches the level of the community-based worker.
Secure adequate storage space in warehouses and facilities.
Ensure that reporting systems provide up-to-date data on co-trimoxazole consumption for
HIV and non-HIV use to inform demand forecasting and supply management.

4.5

Plan for co-trimoxazole use.

Determine what quantities of co-trimoxazole will be given at the first and subsequent clinic
visits; and the procedure to be used for evaluating the infant for resupply.
Review practice codes and laws related to who can dispense co-trimoxazole. Ensure that
nurses, medical officers and community health workers are able to dispense co-trimoxazole
prophylactically.
Disseminate guidelines and develop job aids for all staff responsible for dispensing and
providing medication counselling to clients and caregivers.
Review local knowledge on the determinants of adherence to other paediatric medicines
and take appropriate steps to promote adherence to co-trimoxazole prophylaxis.
Issue guidance on sharing supplies across programmes to respond to stock-outs.

21

V
Rwanda: Managing procurement and supply to support scaling up of co-trimoxazole
prophylaxis
In Rwanda, the Government and Ministry of Health have adopted a policy of providing cotrimoxazole prophylaxis to all HIV-exposed and -infected children. Infants bornto HIV-positive
mothers receive co-trimoxazole prophylaxis for six months following birth. At this point, cotrimoxazole prophylaxis is discontinued for those infants who test negative for HIV. The Ministry
of Health uses the Coordinated Procurement and Distribution System (CPDS) established in
2006 for ARV medicines to coordinate the procurement of co-trimoxazole products among
funders, including the Rwandan Government and its partners. CPDS coordinates the national
quantification of co-trimoxazole products for HIV use and pooled procurement through
Centrale dAchat de Mdicaments Essentiels du Rwanda (CAMERWA), the national public
sector medicine procurement and supply agency, and the leader of the CPDS Implementation
Committee. These estimates are then approved by the Resource Management Commission,
which is chaired by the Permanent Secretary of the Ministry of Health. CAMERWA is also
responsible for quantifying and procuring co-trimoxazole for non-HIV use for public and faithbased health facilities. Procurements are coordinated with the Bureau des Formations Mdicales
Agres au Rwanda (BUFMAR), which also procures and distributes co-trimoxazole to faithbased facilities for non-HIV use. Although the quantification and procurement processes are
not yet integrated, CAMERWA stores and distributes co-trimoxazole supplies for both HIV and
non-HIV use, and the same products are used for both. Public and faith-based health facilities
and district pharmacies report co-trimoxazole consumption for each programme to the central
level in two separate monthly reports to facilitate quantification and reporting to funders.
Source: Personal communications from the Pharmacy Task Force of the Ministry of Health (MOH), the Treatment and
AIDS Research Center (TRAC Plus), CAMERWA, the Permanent Secretary of the MOH and Management Sciences for
Health Strengthening Pharmaceutical Services (MSH/SPS) Rwanda office.

Strategy 5
Strengthen community-based capacity to identify HIV-exposed and -infected infants and
children and refer for testing, care (including initiation and continuation of co-trimoxazole
prophylaxis) and treatment.
Community-based strategies are an important way of optimizing initiation and continued delivery of
co-trimoxazole prophylaxis for children who are exposed to or who have HIV, particularly for families
living far from health centres. Infants and children with HIV will only gain access to diagnosis, care and
treatment if their parents and caregivers, and the frontline health-care workers and nongovernmental
organizations (NGOs) serving the households where they live are informed about how HIV affects
infants and children, that there is hope through early treatment, and how to access these services.

22

V
Relevant actions
5.1

Integrate community-based approaches into MNCH and HIV programming strategies.

For community-based strategies for co-trimoxazole delivery to be effective, several components must
be in place. These include:
Incorporating community strategies for basic HIV care and support, such as monitoring of cotrimoxazole prophylaxis, in national treatment and care plans;
Establishing policies that support the role of community health-care workers to provide basic HIVrelated care such as initiation and monitoring of co-trimoxazole prophylaxis; and
Incorporating co-trimoxazole prophylaxis in the core educational content of community health
workers.
In planning for community-based strategies, the time commitment and caseloads of community
health workers, particularly those who work as volunteers or receive a small stipend, cannot be
expected to be the same as those for full-time workers, who may also earn more substantial financial
compensation for their efforts. For community health workers to be effective, their workload must be
manageable and fit in with their other responsibilities.
5.2

Accelerate case-finding through integration into community health programmes for

other childhood illnesses.

Identifying young children with HIV infection or exposure is important so that they can be given
appropriate care, including co-trimoxazole prophylaxis, and can benefit from life-saving ART.
Community options for case-finding can be built into existing community health services such as
regularly scheduled outreach MNCH services and delivery of integrated services through child
health days, community IMCI, home-based care, community nutrition programmes and other child
care activities driven by NGOs and CBOs. Infants and young children identified as HIV exposed or
suspected of being HIV infected should be initiated on co-trimoxazole prophylaxis and referred for HIV
testing to the nearest facility. Where community IMCI is in place, integrate HIV case-finding and follow
up into protocols, training and referral processes.
5.3

Enhance community capacity to provide co-trimoxazole prophylaxis and other HIVrelated care and support.

Community health workers can be instrumental in sustaining long-term delivery of co-trimoxazole

prophylaxis and ART, as well as other interventions for HIV-infected children such as nutritional and
adherence counselling, psychosocial support , and the management of simple, common side-effects.
The use of peer-to-peer approaches, maternal support groups and community health workers can
help support adherence to co-trimoxazole prophylaxis and ART by ensuring a resupply of medications
and routinely reviewing the health plans with caregivers. Community health workers currently doing
community case management for pneumonia, malaria and diarrhoea are an excellent source of
provision for co-trimoxazole prophylaxis to infants and young children who are HIV-exposed or
-infected.

23

V
Strategy 6
Strengthen monitoring and evaluation systems to support the provision of high-quality care
for children who are exposed to or who have HIV, including the provision of co-trimoxazole
prophylaxis.
WHO and UNICEF have recently reviewed and revised existing guidance on monitoring and evaluation
of services for PMTCT, ART, and HIV care and support.30 The guidance was revised to better reflect
the recent technical revisions to recommendations on ART and HIV care and support, including cotrimoxazole prophylaxis.
The indicator specific to co-trimoxazole prophylaxis reads as follows: Percentage of infants born to
women living with HIV started on co-trimoxazole prophylaxis before two months of age.
6.1

National programmes should ensure that registers used in the HIV and MNCH
programmes contain entry points to capture and record initiation and monitoring of
co-trimoxazole prophylaxis.

Relevant actions
These registers are instrumental in prompting health workers to provide the appropriate service in
a timely manner. They also assist governments in monitoring progress in terms of scale up, and
identifying better- and poorer-performing facilities for documentation of best practices or provision of
supportive supervision.
6.2

Child health cards should be modified to allow for recording of co-trimoxazole

prophylaxis for all HIV-exposed infants.

Child health cards containing HIV-specific information are essential to ensure appropriate follow-up
care for HIV-exposed infants, and can therefore contribute significantly to reduced infant and child
morbidity and mortality (see Appendix C).
6.3

Initiation and adherence monitoring of co-trimoxazole prophylaxis should be selected

as a quality improvement indicator and prioritized as an area for improvement.

Problems with the quality of care being delivered are frequently linked to systems. The quality of HIV
care for children can often be improved by simply introducing basic documentation tools. For example,
introducing a basic checklist into a child health chart can help remind health-care providers about the
importance of specific interventions such as initiation and continuation of co-trimoxazole prophylaxis.

24

V
A quality improvement initiative for co-trimoxazole prophylaxis
The following graphical presentation shows the results of a quality improvement initiative focused
on the administration of co-trimoxazole prophylaxis for HIV-exposed children at three sites in
Lesotho during the period October 2007 to September 2008. Coverage with co-trimoxazole
prophylaxis for HIV-exposed infants improved dramatically, with all sites achieving over 85%
coverage during this period.

Number of children

CTX Prophylaxis Oct-07 Sept-08

700

Exposed Children

586

600

513

500
400

436

382

CTX Prophylaxis

300
200
100

134

127

0
Mabote

Mafeteng

Ntsekhe

Improvement was attributed to the following:

Improved logistics supply management of co-trimoxazole syrup for infants
Ongoing training of staff in the follow up/care of HIV-exposed children
Regular supportive supervision in the Under-5 Clinics
Creation of a one-stop shopping centre for early infant diagnosis and co-trimoxazole
dispensing in MCH settings
Source: Personal communication, International Center for AIDS Care and Treatment Programs, Lesotho

Many facilities in a geographical area may experience similar challenges to the provision of cotrimoxazole prophylaxis. Sharing of experiences between different health facilities can lead to sharing
of successful strategies and overall group learning.

25

V I . CO N CLU S I O N

VI

Co-trimoxazole prophylaxis is safe, inexpensive and highly effective in reducing morbidity and mortality
among HIV-infected infants and children. Ideally, all infants exposed to HIV should be started on cotrimoxazole prophylaxis in the first four to six weeks of life. Coverage, however, remains unacceptably
low. One of the main challenges countries face in scaling up uptake is the absence of mechanisms
to systematically identify and follow up HIV-exposed infants at and after birth. Systems need to be in
place to ensure that health workers consider the possibility of HIV infection in infants at birth, and at all
clinic or other health encounters thereafter, so that this intervention can be provided on a timely basis.
This guide was developed to assist national programme managers and implementing partners
to effectively implement and rapidly scale up the uptake of co-trimoxazole prophylaxis within the
context of existing HIV and MNCH programmes. The specific actions proposed include: (1) enhance
government leadership; (2) deliver co-trimoxazole prophylaxis through existing services; (3) optimize
identification and follow up of HIV-exposed infants and sick infants of unknown HIV status; (4) develop
reliable national- and district-level procurement and supply management mechanisms; (5) strengthen
community capacity to identify HIV-exposed and -infected infants; and (6) strengthen monitoring and
evaluation systems for co-trimoxazole prophylaxis.

26

APPENDICES

APPENDICES

A PPE N D I X A :
W H O recommendations for co -trimoxazole
prophylaxis for infants and children
Table 1. Initiation of co-trimoxazole prophylaxis in infants and children
Situation
HIV-exposed infants
and childrena
Co-trimoxazole
prophylaxis is
universally indicated,
starting at four to six
weeks after birth and
maintained until risk
of HIV transmission
ceases and HIV
infection is excluded

Infants and children confirmed to be living with HIV b

<1 year

14 years

Co-trimoxazole
prophylaxis is
indicated regardless
of CD4 percentage or
clinical statusc

WHO clinical stages 2,

3 and 4 regardless of
CD4 percentage

>5 years
Follow adult
recommendations

OR
Any WHO stage and
CD4 <25%

OR
Universal option: prophylaxis for all infants and children born to mothers confirmed to be or
suspected of living with HIV. This strategy may be considered in settings with a high prevalence of
HIV, high infant mortality due to infectious diseases and limited health infrastructure.

a. Defined as a child born to a mother living with HIV or a child breastfeeding from a mother living with
HIV until HIV exposure stops (six weeks after complete cessation of breastfeeding) and infection
can be excluded.
b. Among children younger than 18 months, HIV infection can only be confirmed by HIV viral testing.
c. Once a child is started on co-trimoxazole, prophylaxis should continue until five years of age
regardless of clinical symptoms or CD4 percentage. Specifically, infants who begin co-trimoxazole
prophylaxis before the age of one year and are subsequently asymptomatic and/or have CD4
levels >25% should remain on co-trimoxazole prophylaxis until they reach the age of five years.

27

APPENDICES

Table 2. Dosages of commonly used co-trimoxazole formulations for infants

and children living with or exposed to HIV

Recommended
daily dosagea

<6 months
or <5 kg

Suspension
(5 ml of syrup
200 mg/40 mg)

(100 mg/20 mg)

Doublestrength
adult tablet

(400 mg/80 mg)

(800 mg/
160 mg)

2.5 ml

One tablet
mixed with feed
or small amount
of milk or water

tablet,
possibly mixed
with feed
or small amount
of milk or water b

5 mlc

Two tablets

Half tablet

10 mlc

Four tablets

One tablet

Half tablet

Two tablets

One tablet

100 mg
sulfamethoxazole/
20 mg trimethoprim
6 months5 years or
515 kg

Child tablet

Single-strength
adult tablet

200 mg
sulfamethoxazole/
40 mg trimethoprim
614 years
or 1530 kg
400 mg
sulfamethoxazole/
80 mg trimethoprim
>14 years
or >30 kg
800 mg
sulfamethoxazole/
160 mg trimethoprim
Frequency once a day
a. Some countries may use weight bands rather than age to determine dosing.
b. Splitting tablets into quarters is not considered best practice. This should be done only if syrup is
not available.
c. Children of these ages (6 months14 years) may swallow crushed tablets.
Source: World Health Organization. Guidelines on co-trimoxazole prophylaxis for HIV-related infections among children,
adolescents and adults. Recommendations for a public health approach. Geneva, WHO, 2006:15 (Table 3). http://www.who.
int/hiv/pub/guidelines/ctxguidelines.pdf 8
(Two tables have been combined to include both age and weight).

28

APPENDICES

Children with a history of treated PCP should be administered secondary co-trimoxazole prophylaxis
with the same regimen recommended for primary prophylaxis.
Table 3. Summary of recommendations for discontinuing primary
co-trimoxazole prophylaxis among infants and children
Target population

Recommendations

HIV-exposed children

Discontinue co-trimoxazole prophylaxis after HIV infection is excluded

Infants and children

living with HIV

Maintain on co-trimoxazole prophylaxis until the age of five years,

irrespective of clinical and immune response
Children older than five years can be reassessed and consideration
given to discontinuing co-trimoxazole prophylaxis in accordance with
the recommendations for adults and adolescents

The general recommendation is that secondary co-trimoxazole prophylaxis should not be discontinued,
irrespective of the clinical and immune response to ART.
Source: World Health Organization. Guidelines on co-trimoxazole prophylaxis for HIV-related infections among children,
adolescents and adults. Recommendations for a public health approach. Geneva, WHO, 2006.Available at: http://www.who.
int/hiv/pub/guidelines/ctxguidelines.pdf (accessed on 28 July 2009).8

29

APPENDICES

A PPE N D I X B :
G E N E R I C H I V A LGO R ITH M U S E D FO R TH E I NTEG R ATE D
M A N AG E M E NT O F C H I LD H O O D I LLN E S S ( I M C I )
THEN CHECK FOR HIV INFECTION*

CLASSIFY

IDENTIF Y
T R E AT M E N T S

Positive HIV
antibody test for
child 18 months and
above

CONFIRMED
HIV INFECTION

Treat, counsel and follow-up existing

infections

Has the mother or child had an HIV test?

OR

SIGNS

Does the child have one or more of the

following conditions?:
Pneumonia**

Give co-trimoxazole prophylaxis

OR

Give vitamin A supplement from 6 months

of age every 6 months

HIV positive
virological test

Assess the childs feeding and provide

appropriate counseling to the mother

Persistent diarrhoea**

Refer for further assessment including HIV

care/ART

Ear discharge (acute or chronic)

Follow-up in 14 days, then monthly for 3

months then every three months or as per
immunization schedule

Very low weight for age**

One or both of the
following

If yes to one of the two questions above,

enter the box below and look for the following
conditions suggesting HIV infection:

HIV EXPOSED/
POSSIBLE HIV

Mother HIV positive

and no test result
for child

Give co-trimoxazole prophylaxis

OR

Assess the childs feeding and provide

appropriate counseling to the mother

Give vitamin A supplement from 6 months

of age every 6 months

Child less than

18 months with
positive antibody
test

N OT E
OR ASK:

LO O K
AND FEEL :

PNEUNOMIA?

Oral Thrush

PERSISTENT

Parotid
enlargement

DIARRHOEA?
EAR
DISCHARGE?

Generalized
persistent
lymphadenopathy

2 or more
conditions

Classify
for HIV
Infection

Treat, counsel and follow-up existing

infections

AND

Confirm HIV infection status of child as soon

as possible with best available test
Follow-up in 14 days, then monthly for 3
months then every three months or as per
immunization schedule

SUSPECTED
SY M P T O M AT I C
HIV INFECTION

Treat, counsel and follow-up existing

infections
Give co-trimoxazole prophylaxis
Give vitamin A supplement from 6 months
of age every 6 months

No test results for

mother and child

Assess the childs feeding and provide

appropriate counseling to the mother
Test to confirm HIV infection

VERY LOW
WEIGHT?

Refer for further assessment including HIV

care/ART
Follow-up in 14 days, then monthly for 3
months then every three months or as per
immunization schedule

*A child who has already been put on ART

does not need to be assessed with this HIV box
**Includes severe forms such as severe
pneumonia... In the case of severe forms, complete
assessment quickly and refer child URGENTLY

Less than two

conditions
AND

SY M P T O M AT I C
HIV INFECTION
U N L I K E LY

No test result for

mother or child
Negative HIV
test result in
mother or child
AND not enough
signs to classify
as suspected
symptomatic HIV
infection

Treat, counsel and follow-up existing

infections
Advise the mother about feeding and about
her own health
Encourage HIV testing

HIV INFECTION
U N L I K E LY

Treat, counsel and follow-up existing

infections
Advise the mother about feeding and about
her own health

Source: World Health Organization/United Nations Childrens Fund. Integrated Management of Childhood Illness for high HIV
settings: chart booklet. Geneva, WHO Department of Child and Adolescent Health, 2008:2021. 25

30

Dead

Alive

Dead

Alive

Date

Medication

Date

Medication

For children aged 12 months and above, 500 mg Mebendazole every six months

DEWORMING

Any other reason for special attention:

Twin child

Number of brothers and sisters

Father dead

Mother dead

Fully protected against Tetanus at birth

Born within 2 years of last delivery

Birth defect/handicap

Birth weight less than 2.5kg

Tick if the child has/is:

Where the family lives: address

Place of Birth:

Birth weight

NRC no.

Fathers or Guardians Name

Date of Birth

NRC no.

Mothers or Guardians Name

Date first seen

Boy/Girl

Childs Name

Childs No.

Name of Health Facility

CHILDS PARTICULARS

Date ..............................

Date ..............................

DPT-HepB-Hib 3

Measles (at 9 months, or soon after.

OPV 4
Unless symptomatic HIV)

31

Vitamin A (1 dose of 200,000 IU) to be given soon after

birth or within two months of delivery.

Date Vit. A given to the mother

MOTHER

0-5 months, 50,000 IU only if not breastfed;

6-11 months,100,000 IU;
12-59 months, 200,000 IU every six months
Date
Dosage
Dosage

VITAMIN A SUPPLEMENTATION

Date

Dosage:

Date
Date

OTHER IMMUNISATIONS

Date .......................................... Date ....................................................

(at 9 months, only if OPV 0

was not given)

(at least 4 weeks after OPV 2)

(at least 4 weeks after DPT-HepB-Hib 2)
Date ........................................... Date .....................................................

OPV 3

(at least 4 weeks after DPT-HepB-Hib1)

Date .................................... Date .....................................................

(at least 4 weeks after OPV 1)

Date ..............................................

DPT-HepB-Hib 2

OPV 2

(at 6 weeks)

OPV 1

Date ....................................

Date .......................................
DPT-HepB-Hib 1 (at 6 weeks)

(at birth to 13 days)

OPV 0

IMMUNISATION against Polio (OPV), Diphtheria, Whooping

Cough, Tetanus, Hib, Hepatitis B, Meningitis, Pneumonia
(DPT-HepB-Hib) & Measles

If no scar after 12 weeks,

repeat dose. Unless symptomatic HIV

BCG (at birth)

IMMUNISATION against Tuberculosis (TB)

IMMUNISATION RECORD

CHILDRENS CLINIC CARD

12
12
18
12

Rapid Test
Rapid Test

8M

9M

6 Weeks 2 Months

6
52

PCR

4M

NR

10M 12M

3M

MSU

PMTCT

15M

5M

18M

6M

IGA

24M

7M

CNE

8M

2M
3M
4M

5M

6M

9M 10M 11M 12M 15M 18M 24M

6W

Continued breast feeding after six months in addition to other foods

Milk based feed after six months in addition to other foods
Other, specify

6)
7)

......................................................................................................................

.......................................................................................................................

Mixed feeding (breast milk and other foods)

Animal Milk

5)

3)
4)

Exclusive Alternative Infant Formula

no other fluids except medicines indicated by medical personnel)

Exclusive breast feeding (in the first 6 months, breast-feeding only, no water,

7M

Birth 6 Days 1M

2)

1)

Feeding Code:

Infant feeding code

Follow up time

Infant feeding code

Follow up time

MONITORING OF INFANT AND YOUNG CHILD FEEDING

Age at initiation of ART.........................................

Date initiated on ART............../.............../.............

Date baby referred for ART............/.........../..........

Cotrimoxazole

Follow up time

Cotrimoxazole

Follow up time

MGA

DATE

Test by:

CE













Feeding during and after illness

Safe food and drinking water
Treatment of diarrhoea
HIV/AIDS
Malaria

DISCUSS

Ministry of Health

Breastfeeding
Complementary feeding
Immunisation
Vitamin A supplementation
Family planning

Health Centre.

The child may have Pneumonia, Go immediately to the nearest

PNEUMONIA

If a child has a cough with:

 Fast Breathing
 Difficulties in breathing
 Difficulties in breast-feeding

Go immediately to the nearest Health Centre.

Note: (dilute 1 sachet of ORS in 1 litre of boiled cooled water)

 Give ORS
 Give extra fluids
 Continue to feed the child.

After each loose stool, do the following:

 If the child is still on breast milk, continue breast feeding.

IF THE CHILD HAS DIARRHOEA

Discuss with a health worker.

 Babies born to HIV positive mothers have special feeding needs.

the first six months of life and continue to breastfeed up to two

years and beyond with adequate complementary feeding from six
months of age unless medically indicated.

IMPORTANT:

 All infants and young children should be breastfed exclusively for

APPENDICES

A PPE N D I X C :
Z A M B I A C H I LD H E A LTH CA R D

Date

Nutritional
status

Advice
given

NUTRITION RECORD

Follow up
date

Birth Weight

Birth Date

32

Kg

Weight (Kgs)

Record of visits and nutrition counselling follow up

Kg

1
3
4

1
3
4

16

16

12
11
10

12
11
10

Continue breastfeeding and

feed the child with 3 main meals
and 2 snacks per day.

Milk

25 26 27 28 29 30 31 32 33 34 35 36

13

13

14

14

15

17

15

18

17

13 14 15 16 17 18 19 20 21 22 23 24

1 - 2 years

19

18

20

21

22

23

Kg

19

20

21

2-3 years

Child may be ill,

needs extra care.

VERY DANGEROUS

Rice

37 38 39 40 41 42 43 44 45 46 47 48

12

13

14

15

16

17

18

19

20

49 50 51 52 53 54 55 56 57 58 59 60

5 years

Use a variety of locally available foods such as

vegetables, kapenta, beans, groundnuts,
sweet potatoes, cassava, millet, rice, fresh milk
or sour milk, fruits, oil.

or give with
nshima.

Add these other

foods to the
babys porridge

4 years

5 years

10

11

12

13

14

15

16

17

18

19

20

21

22

21

23

22

24

25

26

27

28

23

3 main meals and 2 snacks per day

3-5 years

9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

9 10 11 12

7
6

7
6
5

9
8

10

10

11

11

13

14

15

16

17

12

Birth - 6 months - 1 year

3 meals per day

3 main meals and 2 snacks per day

Kg

Suggest feeding the

child at least 5 times
each day.

DANGER SIGN

If inadequate weight gain for 2 months or more, seek

medical attention from a health care provider. If
oedema on both feet, point an arrow on the growth
curve and then seek medical attention from nearest
health centre.

Means the child

is growing well.

GOOD

WATCH THE DIRECTION OF THE LINE SHOWING THE CHILDS GROWTH

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

APPENDICES

APPENDICES

A PPE N D I X D :
SA M PLE D O S I N G CA R D FO R CO -TR I M OX A ZO LE
PRO PH Y L A X I S
COTRIMOXAZOLE PROPHYLAXIS FOR INFANTS AND CHILDREN
DOSING RECOMMENDATIONS
Trimethoprim/sulfamethoxazole
CTX/SMZ, Cotrimoxazole, Septrim, Bactrim

Suspension

Single-Strength Tablet

40 mg TMP/200 mg SMZ per 5ml

80 mg TMP/400 mg SMZ

< 6 months

2.5 ml daily

1/4 tab daily

6 months-5 years

5 ml daily

1/2 tab daily

6-14 years

10 ml daily

1 tab daily

Age

> 14 years

2 single-strength or
one double-strength tab daily

Updated June 2006

PEDIATRIC COTRIMOXAZOLE PROPHYLAXIS

Important prescribing information:
aCotrimoxazole is usually well-tolerated but should be regularly
monitored. Tolerance and adherence should be assessed at
every visit.
aThe most common side effects are gastrointestinal (nausea,
vomiting, diarrhea); these are usually seen within two weeks of
initiation.
aRash and fever are rare but reported side effects in children.
aMarrow suppression may lead to neutropenia and anemia,
and caution is warranted when using cotrimoxazole with other
drugs known to have hematologic toxicity. Where possible,
initiation of cotrimoxazole and zidovudine (AZT, ZDV) should be
separated by 4-6 weeks.
aCotrimoxazole can also cause hepatitis, or asymptomatic
increase in liver enzymes (transaminitis). Where possible,
initiation of cotrimoxazole and nevirapine-containing ART
should be separated by 8-12 weeks.
aContraindications to cotrimoxazole include:
Sulfa allergy
Severe renal insufficiency (creatinine > 3 times normal)
Severe hepatic insufficiency (LFTs > 5 times normal)
aDapsone may be used in place of cotrimoxazole when
necessary. The appropriate dose for children > 4 weeks of age is
2 mg/kg/day.
Important information for parents:
aCotrimoxazole prevents serious infections in children with HIV
and can help them feel better and live longer. It is not an
antiretroviral drug, and does not treat or cure the HIV virus.

PEDIATRIC COTRIMOXAZOLE PROPHYLAXIS

The prophylactic use of cotrimoxazole (Septrim, Bactrim,
TMP/SMX, CTX, trimethoprim/sulfamethoxazole) is a critically
important component of HIV care.
Pneumocystis pneumonia is a common and deadly infection,
frequently seen in infants with HIV. It generally occurs between
three and six months of life, often as the first sign of HIV
infection and before the childs HIV status has been determined.
Cotrimoxazole prophylaxis has been clearly shown to prevent
Pneumocystis pneumonia and to save lives, and national and
international treatment guidelines strongly support its use.
Pediatric cotrimoxazole prophylaxis is recommended for:
aAll HIV-exposed infants (e.g. all infants whose mothers are
known to have HIV) from 4-6 weeks of age until the child is
no longer breast feeding and is determined to be uninfected
aAll HIV-infected infants < 12 months
aAll HIV-infected children 1- 4 years with:
Clinical stage 2, 3 or 4 disease
CD4 < 25 %
aAll HIV-infected children > 5 years with:
Clinical stage 3 or 4 disease
CD4 < 350
aAll HIV-infected infants and children with prior
Pneumocystis pneumonia.
All programs providing HIV/AIDS care should follow local and national treatment guidelines,
which remain the final authority for country-specific protocols.

aCotrimoxazole may be given with or without food.

www.columbia-icap.org

Source: International Center for AIDS Care and Treatment Programs (ICAP). Mailman School of Public Health, Columbia
University, New York, June 2006.

33

APPENDICES

A PPE N D I X E :
R A PI D AS S E S S M E NT TO O L FO R S CA LI N G U P
CO -TR I M OX A ZO LE PRO PH Y L A X I S
The following rapid assessment tool is designed for use at the national and/or local and/or facility
level, and ideally at all three levels. Ideally, specific relevant information from this assessment should
be incorporated into routine assessments related to HIV and/or MNCH care. Information from this
assessment should form the basis for improving policies, operations, training, and community education
and mobilization so that more infants and children are reached with co-trimoxazole prophylaxis.
PROCESS
It is recommended that a review be conducted at sample sites where it is most likely that HIV-infected
children are being seen. In most countries, this will include the following:
ART sites
General paediatric outpatient clinics
Inpatient hospital units
Homes visited by home-based care programmes
PMTCT sites
Health centres in high HIV-prevalence communities
Tuberculosis clinics that see children
Immunization and other child health outreach services.
A. Policy and planning
Answer yes (Y) or no (N) or respond as indicated.

Insert funding total:

34

1.

Is co-trimoxazole prophylaxis for children addressed in national

roll-out plans for HIV care, PMTCT and/or MNCH?

2.

Which programme is responsible for funding co-trimoxazole

products for prophylaxis? How much funding is available in total?

3.

Have adequate resources for the co-trimoxazole prophylaxis rollout/phase-in been identified, taking into account the number of
eligible infants, current consumption and patterns of use?

4.

Does a mechanism exist to coordinate co-trimoxazole prophylaxis

roll-out/phase-in among stakeholders?

5.

Do national ART guidelines, PMTCT guidelines and clinical care

guidelines include co-trimoxazole prophylaxis for HIV-exposed
and HIV-infected children?

6.

Have these guidelines been disseminated to front-line

health workers?

APPENDICES

7.

Does the national treatment or case management guidelines

for malaria, ARI, diarrhoea or dysentery include co-trimoxazole?

8.

Are all required co-trimoxazole products registered in-country?

9.

Is co-trimoxazole for prophylaxis included in the Essential

Medicines List? What are the formulations listed for infants and
children?

10. What is the cost of co-trimoxazole prophylaxis to the patient in

public and private sector pharmacies and health service sites?
11. Is there a policy for user fees and waivers/exemptions
for co-trimoxazole prophylaxis for infants and children?
12. Do policies allow for services that extend access to co-trimoxazole
supply to the community level (for example, community case
management of ARI or malaria?)
B. Systems, health management information systems (HMIS) and operations
Documentation and procedures available to identify and follow up HIV-exposed infants
1.

Is maternal HIV status included on child health cards,

maternal and paediatric record forms and registers?

2.

Is provision of co-trimoxazole prophylaxis included on

child health cards, maternal and paediatric record forms
and registers?

3.

How are co-trimoxazole supplies procured:

Pharmaceutical management
a)______
b)______
c)______

a)______

4.

b)______

a)______
b)______
c)______

5.

a)

for use as an essential medicine?

b)

for use as PCP prophylaxis?

c)

Are the procurement mechanisms for different uses

functionally integrated?

a)

Are there annual quantification exercises that include

management and prophylaxis use?

b)

Is the process inclusive of programmes and partners

for both HIV and non-HIV use?

How are co-trimoxazole supplies distributed:

a)

for use as an essential medicine?

b)

for use as prophylaxis?

c)

Is the storage and distribution of co-trimoxazole

products for different uses functionally integrated?

35

APPENDICES

a1)___ a2)___

6.

Are there any issues with the procurement and

distribution of co-trimoxazole formulations for infants and
children?

7.

Availability of co-trimoxazole products in warehouses

and facilities visited

b1)__ b2)___

a)

for use as an essential medicine

b)

for use as prophylaxis

(1) at the time of visit (percentage of facilities where each

product was available at the time of visit) and
(2) over the past year (average percentage of time out of
stock in the past 612 months)
a)______

8.

b)______
a)______

9.

b)______

Have all orders for the past 6 months been received in full:
a)

for use as an essential medicine?

b)

for use as prophylaxis?

What percentage of stock records correspond with

physical counts for co-trimoxazole products in (a)
warehouses and (b) facilities visited?

10. Is there a policy/guidance on sharing supplies across

programmes to fill gaps in availability?
11. Have requisition and reporting forms been updated to
include co-trimoxazole for prophylactic use?
Prescribing and dispensing practices
12. Which health workers in which facilities are allowed to
dispense co-trimoxazole to infants and children?

a)______

13. Are community health workers allowed to

(a) initiate co-trimoxazole prophylaxis?

b)______

(b) resupply co-trimoxazole prophylaxis after it

has been initiated?
14. Are prescriptions required?

36

APPENDICES

a)______

15. What are the current prescribing practices?

b1)______
b2)______

a)

For which conditions is co-trimoxazole commonly

prescribed?

b)

Are
prescriptions
aligned
with
guideline
recommendations (1) for government facilities, (2) for
the NGO and private sectors, and (3) for community
health workers?

b3)______

16. Have job aids been developed to assist pharmacy and

other dispensing staff to check the doses prescribed,
and counsel patients and caregivers on medication use?
C. Health provider training
_____Nursing

1.

Is content on co-trimoxazole prophylaxis for infants and

children included in the pre-service nursing, medical and
pharmacy school curricula?

2.

Is content on co-trimoxazole prophylaxis for infants and

children included in

_____Medical
_____Pharmacy
a. _______
b. _______

a. __________

3.

b. __________

a)

continuing education/in-service training?

b)

If so, for which cadres of health workers?

Is content on co-trimoxazole prophylaxis for infants and

children included in
a)

adult and paediatric ART training?

b)

What is the duration of training?

D. Knowledge and attitudes of clients and health workers

1.

Please describe ongoing or planned community education

and mobilization activities that include information on
co-trimoxazole prophylaxis. Please attach related job aids
or materials.

2.

Describe PMTCT and other facility-based patient education

efforts around co-trimoxazole prophylaxis for HIV-exposed
and -infected children and non-HIV use of co-trimoxazole.

37

APPENDICES

A PPE N D I X F :
AS S E S S M E NT O F S TA FFI N G N E E D S
Existing staff will need to be assigned specific tasks to ensure all aspects of delivery of co-trimoxazole
prophylaxis, from ordering to prescribing and ensuring adherence. Questions you need to ask to
identify staffing needs include the following:
Who will be responsible for
procuring supplies: assessing stock, placing orders, receiving and storing stock, accounting for
materials?
identifying HIV-exposed infants for initiation of co-trimoxazole prophylaxis and HIV testing (DBS)?
prescribing and dispensing co-trimoxazole, and counselling regarding co-trimoxazole adherence?
data collection and/or data entry, and preparation of summary reports?
evaluating data and presenting feedback to staff on site performance?
training new staff on programme activities and providing supportive supervision?
Adapted from: Abrams EJ, Fayorsey R, Gonzalez LF. Diagnosis of HIV infection in infants: a
comprehensive implementation and clinical manual. New York, Columbia University, Mailman School
of Public Health, International Center for AIDS Care and Treatment Programs, 2007.32

38

APPENDICES

A PPE N D I X G :
R E S OU RC E S FO R CO -TR I M OX A ZO LE PRO PH Y L A X I S
I.

WHO/UNITED NATIONS POLICY STATEMENTS, RECOMMENDATIONS AND GUIDELINES

ON CO-TRIMOXAZOLE PROPHYLAXIS
WHO. Guidelines on co-trimoxazole prophylaxis for HIV-related infections among children,
adolescents and adults. Recommendations for a public health approach. Geneva, WHO, 2006.
http://www.who.int/hiv/pub/guidelines/ctxguidelines.pdf (accessed on 14 August 2009).

II.

GLOBAL MANUALS RELATED TO CO-TRIMOXAZOLE PROPHYLAXIS AND PAEDIATRIC

HIV/AIDS
Abrams EJ, Fayorsey R, Gonzalez LF. Diagnosis of HIV infection in infants: a comprehensive
implementation and clinical manual. New York, Columbia University, Mailman School of Public
Health, International Center for AIDS Care and Treatment Programs, 2007.
African Network for the Care of Children Affected by AIDS (ANECCA). Handbook on paediatric
AIDS in Africa. Revised edition. Kampala, Uganda, ANECCA, July 2006. http://www.anecca.org/
modules/PDdownloads/ (Also available in French)
Baylor International Pediatric AIDS Initiative (BIPAI). HIV curriculum for the health professional.
Third edition. Houston, TX, BIPAI, 2007. http://www.bayloraids.org/curriculum/ (Also available in
multiple languages)
Expanded Inter-Agency Task Team (IATT) on Prevention of HIV infection in Pregnant Women,
Mothers and their Children. A report card on prevention of mother-to-child transmission of HIV
and paediatric HIV care and treatment in low- and middle-income countries: scaling up progress
from 2004 to 2005. New York, IATT, February 2007.
Hope R, Israel E. The essentials of antiretroviral therapy for health care and program managers.
Watertown, Massachusetts, Pathfinder International, 2007 (Technical Guidance Series Number 5).
International Center for AIDS Care and Treatment Programs (ICAP). Care of the HIV-exposed
infant. New York, Columbia University, Mailman School of Public Health. http://www.columbiaicap.org/resources/peds/trainingresources/care_hiv_infant.pdf (accessed on 27 July 2009).
WHO/UNICEF. Scale up of HIV-related diagnosis, care, support and treatment of infants and
children: a programming framework. Geneva, WHO/UNICEF, 2008. http://www.who.int/hiv/
paediatric/Paeds_programming_framework2008.pdf (accessed on 27 July 2009).
WHO. Antiretroviral therapy of HIV infection in infants and children in resource-limited settings:
toward universal access. Recommendations for a public health approach. Geneva, WHO, 2006.
http://www.who.int/hiv/pub/guidelines/art/en/index.html (accessed 13 August 2009).
WHO/UNICEF. Management of HIV infection and antiretroviral therapy in infants and children: a
clinical manual. New Delhi, WHO SEARO, 2006.
WHO/UNICEF. Guidance on the global scale-up of the prevention of mother-to-child transmission
of HIV: towards universal access for women, infants and young children and eliminating HIV and
AIDS among children. Geneva, WHO, 2007.

39

APPENDICES

R E FE R E N C E S
1 Joint United Nations Programme on HIV/AIDS. 2008 Report on the global AIDS epidemic. Geneva, UNAIDS, 2008.
2 World Health Organization. Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants:
towards universal access: recommendations for a public health approach. Geneva, WHO, 2006:5. http://www.who.int/
hiv/pub/mtct/arv_guidelines_mtct.pdf (accessed on 09 August 2009).
3 United Nations Childrens Fund/Joint United Nations Programme on HIV/AIDS/World Health Organization. Children and
AIDS: second stocktaking report. New York, UNICEF/UNAIDS/WHO, 2008.
4 Joint United Nations Programme on HIV/AIDS/World Health Organization/ United Nations Childrens Fund. Towards
universal access: scaling up priority HIV/AIDS interventions in the health sector. Progress report 2009. Geneva, UNAIDS,
WHO, UNICEF, 2009.
5 Violari A et al for the CHER Study Group. Early antiretroviral therapy and mortality among HIV-infected infants. New
England Journal of Medicine, 2008, 359:22332244.
6 World Health Organization. Early detection of HIV infection in infants and children: guidance note on the selection of
technology for the early diagnosis of HIV in infants and children. Geneva, WHO, 2007. http://www.who.int/hiv/paediatric/
EarlydiagnostictestingforHIVVer_Final_May07.pdf (accessed on 29 July 2009).
7 Expanded Inter-Agency Task Team (IATT) on Prevention of HIV infection in Pregnant Women, Mothers and their Children.
A report card on prevention of mother-to-child transmission of HIV and paediatric HIV care and treatment in low- and
middle-income countries: scaling up progress from 2004 to 2005. New York, IATT, February 2007.
8 World Health Organization. Guidelines on co-trimoxazole prophylaxis for HIV-related infections among children,
adolescents and adults. Recommendations for a public health approach. Geneva, WHO, 2006 . http://www.who.int/hiv/
pub/guidelines/ctxguidelines.pdf (accessed 14 August 2009).
9 Chintu C et al. Cotrimoxazole as prophylaxis against opportunistic infections in HIV-infected Zambian children (CHAP): a
double-blind randomised placebo-controlled trial. The Lancet, 2004, 364:18651871.
10 Marinda E et al. Child mortality according to maternal and infant HIV status in Zimbabwe. Pediatric Infectious Diseases
Journal, 2007, 26:519526.
11 Mulenga V et al. Effect of cotrimoxazole on causes of death, hospital admissions and antibiotic use in HIV-infected
children. AIDS, 2007, 21:7784.
12 Thera MA et al. Impact of trimethorpimsulfamethoxazole prophylaxis on falciparum malaria and disease. Journal of
Infectious Diseases, 2005, 192:18231829.
13 Nunn AJ et al. for the UNZA-UCLMS Project LUCOT Collaboration. Role of co-trimoxazole prophylaxis in reducing
mortality in HIV infected adults being treated for tuberculosis: randomised clinical trial. British Medical Journal, 2008,
337:a257 (doi: 10.1136/bmj.a257).
14 Zachariah R et al. Scaling-up co-trimoxazole prophylaxis in HIV-exposed and HIV-infected children in high HIV-prevalence
countries. Lancet Infectious Diseases, 2007, 7:686693.
15 World Health Organization. Taking stock: HIV in children. The state of affairs. Geneva, WHO, 2006. http://www.who.int/
hiv/toronto2006/takingstockchildren.pdf (accessed on 29 July 2009).
16 Ginsburg AS et al. Provision of care following prevention of mother-to-child HIV transmission services in resource-limited
settings. AIDS, 2007, 21:25292532.
17 World Health Organization. Priority interventions: HIV/AIDS prevention, treatment and care in the health sector. Version
1.1. Geneva, WHO, 2008. http://www.who.int/hiv/pub/priority_interventions_web_c1.pdf (accessed on 29 July 2009).
18 World Health Organization. Guidance on provider-initiated HIV testing and counselling in health facilities. Geneva, WHO,
2007. http://www.who.int/hiv/pub/guidelines/pitc2007/en/index.html (accessed on 29 July 2009).
19 World Health Organization. Antiretroviral therapy of HIV infection in infants and children: towards universal access.
Recommendations for a public health approach. Geneva, WHO, 2007. http://www.who.int/hiv/pub/guidelines/art/en/
index.html (accessed 13 August 2009).

40

APPENDICES

20 World Health Organization. HIV and infant feeding. Geneva, WHO, 2008. http://www.who.int/child_adolescent_health/
documents/9789241595964/en/index.html (accessed 13 August 2009).
21 Tuberculosis Coalition for Technical Assistance. International standards for tuberculosis care. The Hague, TBCTA, 2006.
http://www.who.int/tb/publications/2006/istc_report.pdf (accessed on 29 July 2009).
22 World Health Organization. Pregnant women and infants. Geneva, WHO Global Malaria Programme, http://apps.who.int/
malaria/malariainpregnancy.html, and http://apps.who.int/malaria/malariaininfants.html (accessed on 10 August 2009).
23 World Health Organization. Guidelines for the treatment of malaria. Geneva, WHO, 2006. http://www.who.int/malaria/
pregnantwomenandinfants.html (accessed on 10 August 2009).
24 World Health Organization. Integrated Management of Childhood Illness. Geneva, WHO, 2008. http://whqlibdoc.who.int/
publications/2008/9789241597289_eng.pdf (accessed on 10 August 2009).
25 World Health Organization/United Nations Childrens Fund. Integrated Management of Childhood Illness for high HIV
settings: chart booklet. Geneva, WHO Department of Child and Adolescent Health, 2008:2021.
26 Mazia G et al. Integrating quality postnatal care into PMTCT in Swaziland. Global Public Health Journal, 2009 (in press).
27 HIV Unit, Department of Clinical Services, Ministry of Health; National TB Control Program; Lighthouse Trust, Lilongwe;
and the United States Centers for Disease Control and Prevention, Malawi. Report of a country-wide survey of HIV/AIDS
services in Malawi for the year 2006. Lilongwe, HIV Unit, Department of Clinical Services, Ministry of Health, 2006.
28 Management Sciences for Health/World Health Organization. International drug price indicator guide. Arlington, VA, MSH,
2007. http://erc.msh.org/mainpage.cfm?file=1.0.htm&module=DMP&language=English (accessed on 13 August 2009)
29 World Health Organization. Transaction prices for antiretroviral medicines and HIV diagnostics from 2004 to September
2008. Geneva, WHO Global Price Reporting Mechanism, 2008. http://www.who.int/hiv/amds/gprm/en/index.html, and
http://www.who.int/hiv/amds/GPRMsummaryReportOct2008.pdf (accessed on 29 July 2009).
30 WHO. Monitoring and evaluating the prevention of mother-to-child transmission of HIV: a guide for national programmes.
Geneva, WHO, September 2009.
31 International Center for AIDS Care and Treatment Programs (ICAP). Care of the HIV-exposed infant. New York, Columbia
University, Mailman School of Public Health, June 2006.
32 Abrams EJ, Fayorsey R, Gonzalez LF. Diagnosis of HIV infection in infants: a comprehensive implementation and clinical
manual. New York, Columbia University, Mailman School of Public Health, International Center for AIDS Care and
Treatment Programs, 2007.

41

NOTES

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43

This document was written on behalf of the Expanded Inter-Agency Task Team (IATT) on Prevention
of HIV Infection in Pregnant Women, Mothers and their Children and with the collaboration of multiple
organizations working to improve pediatric HIV prevention, care and treatment.

For more information, please contact any of the organizations which supported the development of this
document.
ISBN 978 92 4 159863 7