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 Table of Contents  
Year : 2017  |  Volume : 4  |  Issue : 2  |  Page : 31-36

Knowledge regarding co-trimoxazole preventive therapy among patients who are HIV positive in a tertiary health facility, northeastern Nigeria

Department of Medicine, College of Medical Sciences, University of Maiduguri, Borno State, Nigeria

Date of Web Publication29-Mar-2018

Correspondence Address:
Ballah Akawu Denue
Department of Medicine, College of Medical Sciences, PMB 1069, University of Maiduguri, Borno State
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ssajm.ssajm_22_16

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Background: Co-trimoxazole (sulfamethoxazole and trimethoprim, CTX) is known to be effective against common opportunistic infections associated with severe immunosuppression such as AIDS. Its use among patients with defects in immunity and multiple infections is associated with significant reduction in morbidity and mortality.
Objective: To determine and predict the level of knowledge regarding co-trimoxazole preventive therapy (CPT) among patients with HIV.
Materials and Methods: This was a descriptive cross-sectional study conducted among 358 patients who were HIV positive. An expert-validated, interviewer-administered questionnaire with Cronbach alpha of 0.67 was used to assess patients’ knowledge regarding CPT.
Results: Most respondents, 323 (90.2%) in total, reported not to have ever been counseled on CPT. The proportion of those counseled showed female preponderance, with 26 females (74.3%) compared with nine males (25.7%). Among those who responded to ever been counseled, only 19% had questionnaire-defined (≥50% score) adequate knowledge. The level of education and counseling regarding CPT were independent predictors of knowledge. Patients with secondary and tertiary education were three times [P = 0.021, odds ratio (OR) = 3.098, 95% confidence interval (CI) = 1.187–8.084] and 18.7 times (P < 0.001, OR = 18.764, CI = 6.862–51.313) likely to demonstrate having adequate knowledge than those without formal education. Similarly, adherence counseling was associated with 16 times greater chance for demonstrating adequate knowledge (P < 0.001, OR = 16.063, CI = 5.768–44.733).
Conclusion: Knowledge on the use of CPT is poor in our setting; adherence counseling on its use is recommended at services delivery points.

Keywords: Co-trimoxazole (sulfamethoxazole and trimethoprim,, CTX), HIV infection, opportunistic infection, preventive therapy

How to cite this article:
Denue BA. Knowledge regarding co-trimoxazole preventive therapy among patients who are HIV positive in a tertiary health facility, northeastern Nigeria. Sub-Saharan Afr J Med 2017;4:31-6

How to cite this URL:
Denue BA. Knowledge regarding co-trimoxazole preventive therapy among patients who are HIV positive in a tertiary health facility, northeastern Nigeria. Sub-Saharan Afr J Med [serial online] 2017 [cited 2023 Mar 27];4:31-6. Available from: https://www.ssajm.org/text.asp?2017/4/2/31/228960

  Introduction Top

Co-trimoxazole (CTX) is an antibiotic with a good safety profile that is effective against several bacterial, fungal, and protozoal infections. Its use for therapeutic and prophylaxis against infection in sub-Saharan countries with high Human Immunodeficiency Virus (HIV) prevalence has been shown to remarkably reduce morbidity and mortality and improve survival among patients with HIV.[1] As a result of this evidence-based significance of CTX in HIV management, the World Health Organization (WHO) and United Nations Programme on HIV/AIDS (UNAIDS) recommend CTX be given to all patients (adults and children) in Africa living with Acquired Immunodeficiency Syndrome (AIDS), HIV–Tuberculosis (TB) coinfection, symptomatic HIV infection in WHO clinical stages ≥2, and those with CD4 cell count <350 cells/μl.[2] Other researchers are of the opinion that the drug should be administered to all adults infected by HIV.[3] Several studies conducted in African countries such as Cote d’Ivoire,[4] Uganda,[5],[6] Malawi,[7] and South Africa[8] showed significant benefits by co-trimoxazole preventive therapy (CPT). A study conducted in Zambia demonstrated significant benefit despite the reported high level of bacterial resistance to CTX in the region.[9]

Despite overwhelming evidence on the benefits of CPT especially in sub-Saharan Africa[10] and the guidelines and recommendations from the WHO and UNAIDS that CPT be offered to all individuals living with AIDS, including patients who are HIV positive with TB, its routine use in developing countries particularly Africa has been reported to be dismissal.[11]

Against this background, we assessed knowledge regarding CPT and associated factors among patients who were HIV positive. The findings from this study, in our view, are intended to address factors, if any, militating against the uptake of CPT among patients with HIV accessing care at the University of Maiduguri Teaching Hospital Maiduguri, a designated center of excellence for infectious diseases and immunology and the largest antiretroviral treatment (ART) center in northeastern Nigeria.

  Materials and method Top

Study setting

The study was conducted at the ART unit of the Pharmacy Department, University of Maiduguri Teaching Hospital (UMTH). It is a designated center of excellence in Infectious diseases and Immunology and one of the largest healthcare facilities in northeastern Nigeria with a 530-bed capacity. The hospital provides tertiary health services to the residents of northeastern Nigeria and the neighboring countries within the lake Chad Commission, that is, Chad, Cameroon, and Niger Republic.

Maiduguri, the capital of Borno State, is among the largest cities in northeastern Nigeria with an estimated population of 728,539. It lies on latitude 115°N and longitude 135°E, and occupies an area of 50,778 square kilometers. The climate of Maiduguri is favorable, with a mean annual temperature of 34.8°C.

Study design

This is a cross-sectional descriptive study conducted between May and October 2014 at the ARV Pharmacy unit, University of Maiduguri Teaching Hospital.

Study population

A total of 5476 adult (≥16 years) patients infected by HIV and on CPT assessing care in UMTH were eligible for the study.

Sample size

A sample size of 358 was obtained by systematic random sampling using the formula (Araoye, 2004):[12]

where N = sample frame (5476), n = sample size for a population >10,000, and nf = desired sample size for population <10,000.

n (sample size for a population > 10,000) = 384 as derived from:

where z = 1.96 [standard normal deviation at 95% confidence interval (CI)], P = proportion of the population expressing certain characteristics 50% (0.5), and D = degree of freedom (0.05).

Research instrument

An expert-validated, interviewer-administered questionnaire with Cronbach alpha of 0.67 was used to assess patients’ knowledge regarding CPT. The questionnaire had 17 questions in three sections: one section was on sociodemographic data such as age, gender, and the level of education, second section had seven questions targeted at evaluating knowledge, and the final section was regarding suggestions on the services of the unit.

Each of the seven questions targeted at evaluating knowledge was awarded one (1) score for correct response and zero (0) score for wrong response.

Operational definitions


Is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed about the drug and to make appropriate decisions.

Knowledge regarding co-trimoxazole preventive therapy

Is the degree to which patients on CPT have the capacity to obtain, process, and understand basic information on indication, dosing, and common side effects of the drug CTX.

Adequate knowledge

In this study, it is used to describe a patient who scored at least 50% on answering the seven questions framed to evaluate knowledge regarding CPT.

Data collection

Data were collected using questionnaires distributed to patients who were HIV positive and taking CPT. Respondents who could not read or write were guided by the research assistant and the principal investigator in their native language.

Ethical issues

Ethical approval was obtained from the research and ethics committee of the UMTH prior to the commencement of the study.

Data analysis

The data were analyzed using the Statistical Package for the Social Sciences version 16.0 software (SPSS Inc., Chicago, IL, USA). The results were presented as a table and bar chart with simple frequency and percentages. Proportion was compared using chi-square analysis. Univariate and multivariate regression analyses were conducted to identify factors predicting the level of knowledge regarding CPT. P value < 0.05 was considered statistically significant.

  Results Top

Baseline sociodemographic characteristics of the studied participants

Of the 356 patients who participated in this study, the proportion of females at 224 (62.6%) was higher than that of males (P < 0.001); conversely, males were older with a mean age [standard deviation (SD)] of 34.4 years (10.2) than the 32 years (9.0) for females (P = 0.027). Patients aged 31–40 years constituted the majority (42.3%) of the respondents. About one out of two participants (51.4%) had no formal education, while those with tertiary literacy level of education constituted 12.0% of the participants. The literacy level showed a male preponderance (P = 0.041). The distribution of the participants on the basis of defined duration on ART (0–2, 3–5 and >5) years was similar (P = 0.300). Only 35 respondents (9.8%) admitted to have had adequate adherence counseling on CPT. There was no significant gender variation based on duration CPT, as depicted in [Table 1].
Table 1: Baseline sociodemographic characteristics

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Seven questions were directed toward evaluating knowledge. Participants who scored 50% and above were considered to have adequate knowledge. Only 19% of the studied participants demonstrated having adequate knowledge regarding CPT, as shown in [Figure 1].
Figure 1: Level of knowledge of the study population

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Univariate analysis of factors affecting co-trimoxazole preventive therapy

On univariate analysis, as shown in [Table 2], literacy level and adherence counseling regarding CPT significantly affected the level of knowledge. Participants with no formal education and primary education had lower and similar levels of knowledge on CPT. Responders who had secondary and tertiary literacy levels demonstrated having four times [P < 0.001, odds ratio (OR) = 4.006, CI = 1.841–8.716] and 21 times (P < 0.001, OR = 21.031, CI = 9.264–47.743) better knowledge regarding CPT, respectively than those who had no formal education (referent). There was an observed significant association between counseling and knowledge regarding CPT (P < 0.001, OR = 23.213, CI = 9.879–54.544). Being within the age group of 21–30 years had significant correlation with the level of knowledge (P = 0.034, OR = 0.033, CI = 0.001–0.770). There was no significant association between duration on ART in years and knowledge regarding CPT.
Table 2: Univariate analysis of factors affecting knowledge regarding CPT

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Multivariate analysis of factors affecting knowledge regarding co-trimoxazole preventive therapy

After adjusting for confounding variables on multivariate analysis, the level of education and adherence counseling persist as independent predictors of knowledge, as shown in [Table 3]. Patients with secondary level of education (P = 0.021, OR = 3.098, CI = 1.187–8.084) were about three times more likely to demonstrate having adequate knowledge regarding CTX use than patients without any formal education. Patients with tertiary level of education (P < 0.001, OR = 18.764, CI = 6.862–51.313) were 18.7 times more likely to demonstrate having adequate knowledge regarding CTX use than the referent population. Patients who had received counseling on CTX use were 16 times more likely to demonstrate having adequate knowledge regarding CTX use than the population that had never received adherence counseling regarding CPT (P < 0.001, OR = 16.063, CI = 5.768–44.733).
Table 3: Multivariate analysis of factors affecting knowledge regarding CPT

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  Discussion Top

CTX is a well-tolerated, inexpensive, and cost-effective antimicrobial against some bacterial diseases such as pneumonia, diarrhea, malaria, and other opportunistic infections. Its use in preventive therapy is associated with fewer hospital admission, decreased morbidity and mortality, and increased survival among people living with HIV and AIDS.[1],[2],[3] Several studies conducted in Africa have demonstrated the positive health benefits of CPT in individuals infected by HIV.[4],[5],[6],[7],[8] Two studies conducted in Zambia, a region with a reported high level of bacterial resistance to CTX, revealed a significant reduction in hospital admissions and death with improved survival among both children[9] and adults[13] infected by HIV.

Because of the benefit of CTX as a preventive therapy especially in sub-Saharan Africa that bears the highest burden of HIV infection, with most mortality due to opportunistic infections, the WHO and UNAIDS have jointly issued provisional recommendations to administer CTX to patients infected by HIV in Africa.[1],[2],[11] In Nigeria, the integrated national guidelines for HIV prevention treatment and care strongly recommend the use of CTX as a preventive therapy.[14] However, despite its tremendous benefits in reducing morbidity and preventing potentially fatal infections such as Pneumocystis jiroveci pneumonia and cerebral toxoplasmosis, the routine use of CTX as a preventive therapy especially in sub-Saharan Africa remains minimal.[10]

The use of CTX for both the primary and secondary prevention of opportunistic infections associated with immunosuppression such as HIV infection is associated with decrease morbidity and mortality and improvement in survival. However, there are concerns about its effectiveness in areas with high bacterial resistance. Administering CTX for preventive measures increases the chance of cross-resistance to sulphadoxine–pyrimethamine (Fansidar SP), which is still the drug of choice for malaria in some malaria endemic regions.[10],[11],[12],[13]

Other factors that may be responsible for the slow implementation of the drug include differences in the burden of opportunistic infections, pill burden, the lack of guidelines for the duration of therapy, and inadequate provisions regarding CPT for all patients who are HIV positive in developing countries.[7],[10],[13]

Majority of the participants in this study had inadequate knowledge regarding CPT. Our finding of 19% of the participants with inadequate knowledge regarding CPT was lower than that observed in a study by Perera et al.[15] among patients receiving care in the Cardiology Unit in Sri Lanka. Perera et al. reported that 36.5% of their studied participants demonstrated having good knowledge regarding their medication. Conversely, a similar study conducted in South Africa revealed that the majority of the population demonstrated having adequate knowledge regarding HIV-related medications including CPT.[16]

Only 32 (9.8%) of our participants had adequate adherence counseling regarding CPT. Although most patients admitted taking CTX, they assumed it was a component of ART; they were unaware of its role in preventive therapy against opportunistic infections. Our finding of poor knowledge regarding CPT is rather not surprising, because 51.4% of the studied participants recruited through systematic random sampling had no formal education.

Furthermore, a possible explanation for inadequate knowledge regarding CPT is the practice of group rather than individual counseling of patients; most of the patients have low literacy levels in our busy clinic, which has a dearth of infrastructure and manpower. Several studies have demonstrated the presence of a positive correlation between patient’s perception on prescribed medication and the level of adherence to the medication. Negative perception toward medication impacts negatively on commitment to adherence. Additionally, perceived knowledge of the benefits from the medication also influences adherence; poor knowledge regarding the benefits of CTX may affect adherence practice and, thus, affect the expected outcome of CPT as demonstrated by other previous studies.[10],[15]

In this study, the level of education and adherence counseling were independent predictors of patients’ knowledge regarding CPT. Respondents with secondary and tertiary levels of education were 3 and 18 times, respectively more likely to have more knowledge than those without formal education. This effect of the level of education on patients’ knowledge regarding medication has been demonstrated by several studies from other developing countries such as Sri Lanka,[15] Uganda,[5] and Zambia.[13] This is, however, inconsistent with that of the study in South Africa by Nachega et al.,[16] which only identified age as the independent predictor of knowledge regarding HIV medication.

Participants in this study who had adherence demonstrated higher knowledge about their medication. Similarly, a study conducted at Brigham and Women’s Hospital, Boston, showed that sound adherence counseling was associated with fewer incidences and less worsening of adverse side effects.[17] The poor level of knowledge among patients with HIV in our facility may largely be attributable to the low level of education and adherence counseling on CPT.

  Conclusion Top

CPT is an amply researched intervention that is associated with decreased morbidity and mortality and increased longevity among patients with HIV. Knowledge regarding the benefits of this highly efficacious and cost-effective intervention is poor among patients who were HIV positive in our setting.


Patient education on the benefits of CPT should form a part of HIV counseling. Compliance with CPT as stipulated by WHO, UNAIDS, and also by Nigerian integrated national guidelines for HIV prevention, treatment, and care is advocated.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

World Health Organization. Guidelines on Cotrimoxazole Prophylaxis for HIV-Related Infections Among Children, Adolescents and Adults, Recommendations for a Public Health Approach. Geneva: World Health Organization; 2006. p. 1-68. Available from: www.who.int/hiv/pub/guidelines/WHO%20CTX.pdf. [Last accessed on 2017 Jan 10].  Back to cited text no. 1
UNAIDS. Provisional WHO/UNAIDS Secretariat Recommendations on the Use of Cotrimoxazole Prophylaxis I Adults and Children Living with HIV/AIDS in Africa. Geneva, Switzerland: UNAIDS; 2000.  Back to cited text no. 2
Mermin J, Lule JR, Ekwaru JP, Pitter C. Should cotrimoxazole prophylaxis be taken by all adults with HIV in Africa? AIDS 2005;19:845-6.  Back to cited text no. 3
Yazdanpanah Y, Losina E, Anglaret X, Goldie SJ, Walensky RP, Weinstein MC et al. Clinical impact and cost-effectiveness of co-trimoxazole prophylaxis in patients with HIV/AIDS in Cote d’Ivoire: A trial-based analysis. AIDS 2005;19:1299-308.  Back to cited text no. 4
Mermin J, Lule J, Ekwaru JP, Malamba S, Downing R, Ransom R et al. Effect of co-trimoxazole prophylaxis on morbidity, mortality, CD4-cell count, and viral load in HIV-infection in rural Uganda. Lancet 2004;364:1428-34.  Back to cited text no. 5
Watera C, Todd J, Muwonge R, Whitworth J, Nakiyingi-Miiro J, Brink A et al. Feasibility and effectiveness of cotrimoxazole prophylaxis for HIV-1 infected adults attending an HIV/AIDS clinic in Uganda. J Acquir Immune Defic Syndr 2006;42:373-8.  Back to cited text no. 6
Mwaungulu FB, Floyd S, Crampin AC, Kasimba S, Malema S, Kanyongoloka H et al. Cotrimoxazole prophylaxis reduces mortality in human immunodeficiency virus-positive tuberculosis patients in Karonga district, Malawi. Bull World Health Organ 2004;82:354-63.  Back to cited text no. 7
Grimwade K, Sturm AW, Nunn AJ, Mbatha D, Zungu D, Gilks CF. Effectiveness of cotrimoxazole on mortality in adults with tuberculosis in rural South Africa. AIDS 2005;19:163-8.  Back to cited text no. 8
Chintu C, Bhat GJ, Walker AS, Mulenga V, Sinyinza F, Lishimpi K et al. Cotrimoxazole as prophylaxis against opportunistic infections in HIV-infected Zambian children (CHAP): A double-blind randomised placebo-controlled trial. Lancet 2004;364:1865-71.  Back to cited text no. 9
Zachariah R, Massaquoi M. Cotrimoxazole prophylaxis for HIV-positive TB patients in developing countries. Trop Doc 2006;36:79-82.  Back to cited text no. 10
World Health Organization/UNAIDS/UNICEF. Joint WHO/UNAIDS/UNICEF Statement on Use of Cotrimoxazole as Prophylaxis in HIV Exposed and HIV Infected Children. WHO/UNAIDS/UNICEF; November 2004.  Back to cited text no. 11
Araoye MO. Sample size determination. In: Margaret OA, editor. Research Methodology with Statistics for Health and Social Workers. Ilorin: Nathadex Publishers, 2004. p. 115-21.  Back to cited text no. 12
Nunn AJ, Mwaba P, Chintu C, Mwinga A, Darbyshire JH, Zumla A. Role of co-trimoxazole prophylaxis in reducing mortality in HIV infected adults being treated for tuberculosis: Randomised clinical trial. BMJ 2008;337:a257.  Back to cited text no. 13
Federal Ministry of Health. Guideline for the Use of Antiretroviral (ARV) Drugs in Nigeria; 2005. p. 59-60.  Back to cited text no. 14
Perera T, Ranasinghe P, Perera S, Adikori M, Jayasinghe S, Godwin RS. Knowledge of prescribed medication information among patients with limited English proficiency in Sri Lanka. BMC Res Notes 2012;5:658. doi: 10.1186/1756-0500- 5-658.  Back to cited text no. 15
Nachega JB, Lehman DA, Hlatshawayo D, Mothopeng R, Chaisson RE, Kartaedt AS. HIV/AIDS and antiretroviral treatment knowledge, attitudes, beliefs and practice in HIV infected adults in Soweto, South Africa. J Acquire Immune Defic Syndr 2005;38:196-201.  Back to cited text no. 16
Schinipper JL, Kirwin JL, Cotugno MC, Wahstrom SA, Brown BA, Tervin E et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med 2006;166:565-71.  Back to cited text no. 17


  [Figure 1]

  [Table 1], [Table 2], [Table 3]

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