Reduced bacterial skin infections in HIV-infected African children randomized to long-term cotrimoxazole prophylaxis

Objective

To evaluate whether cotrimoxazole prophylaxis prevents common skin conditions in HIV-infected children.

Design

Open-label randomized controlled trial of continuing versus stopping daily cotrimoxazole (post-hoc analysis).

Setting

Three sites in Uganda, one in Zimbabwe.

Participants

758 children aged >3 years receiving antiretroviral therapy (ART) for >96 weeks in the ARROW trial were randomized to stop (n=382) or continue (n=376) cotrimoxazole after median(IQR) 2.1(1.8,2.2) years on ART.

Intervention

Continuing versus stopping daily cotrimoxazole.

Main Outcome Measures

Nurses screened for signs/symptoms at 6-weekly visits. This was a secondary analysis of ARROW trial data, with skin complaints categorized blind to randomization as bacterial, fungal, or viral infections; dermatitis; pruritic papular eruptions (PPE); or other (blisters, desquamation, ulcers, urticaria). Proportions ever reporting each skin complaint were compared across randomized groups using logistic regression.

Results

At randomization, median(IQR) age was 7(4,11) years and CD4 was 33%(26,39); 73% had WHO stage 3/4 disease. Fewer children continuing cotrimoxazole reported bacterial skin infections over median 2 years follow-up (15% versus 33%, respectively; P<0.001), with similar trends for PPE (P=0.06) and other skin complaints (p=0.11), but not for fungal (P=0.45) or viral (P=0.23) infections or dermatitis (P=1.0). Bacterial skin infections were also reported at significantly fewer clinic visits (1.2% vs 3.0%, P<0.001). Independent of cotrimoxazole, bacterial skin infections were more common in children aged 6-8 years, with current CD4<500 cells/mm3, WHO stage 3/4, less time on ART and lower socioeconomic status.

Conclusions

Long-term cotrimoxazole prophylaxis reduces common skin complaints, highlighting an additional benefit for long-term prophylaxis in sub-Saharan Africa.