Combined effect of co-trimoxazole preventive therapy and improved water supply interventions on diarrhea amongst HIV-exposed infants and people living with HIV
Authors: Chavura Elton , Singini Wales , Chidya Russel , Mbakaya Balwani Chingatichifwe 
Published: April 2022

Abstract
BackgroundUnsafe sanitation disproportionally affects the most vulnerable groups in society such as HIV-exposed infants (HEI) and people living with HIV/AIDS (PLWHA). Whilst there is emerging body of evidence on benefits of integration of Water, Sanitation and Hygiene (WaSH) and HIV/AIDS, experiences from sub-Saharan Africa has shown that there is insufficient research on what WaSH and HIV/AIDS mainstreaming means in practice for these two sectors. In view of inadequate national integration policies, guidelines and frameworks, the potential health improvements achievable by WaSH investment on HIV may fail to substantially improve the desired health outcomes. Therefore, the question that this systematic review tries to resolve is: What is the combined effect of improved water supply interventions and cotrimoxazole preventive therapy on frequency and severity of diarrhea among HIV exposed infants and PLWHA? MethodsWe examined existing literature on effect of co-trimoxazole and improved water supply interventions on diarrhea amongst PLWHA and HEI. We systematically searched for articles in PubMed, EMBASE, PsycINFO, AMED, CINAHL, DOAJ and Google Scholar databases guided by the acceptance practice developed by PROSPERO and COCHRANE for systematic search and selection of studies. A PRISMA flow diagram was used to explain on the number of articles retrieved, retained, excluded and justifications for every action. Relevant articles and abstracts were gathered, reviewed and prioritized by thematic outcomes of interest. A Mixed Method Appraisal Tool (MMAT) was used to assess the quality of the methodology that was used. All studies that sought to establish the efficacy of co-trimoxazole alongside other proven forms of healthcare preventive packages for HEI and PLWHA such as improved water supply and hygiene interventions were selected for evaluation.ResultsImproved water supply interventions and co-trimoxazole prophylaxis together reduced diarrhea episodes by 67% (IRR _ 0.33, 95% CI 0.24–0.46, P < 0.0001), days with diarrhea (5.5 versus 10.5 days per person-years; IRR_0.46, 95% CI_0.32–0.66, P < 0.0001), and days of work or school lost due to diarrhea. The combined interventions resulted in 27% risk reduction in HIV disease progression whilst safe water alone was associated with reductions in the longitudinal prevalence of reported diarrhea of 53% among HIV exposed infants aged ≤2 years (LPR = 0.47, 95% CI: 0.30–0.73, P < 0.001) and 54% among all household members (LPR = 0.46, 95% CI: 0.30–0.70, P < 0.001). The overall quality of evidence of studies examining mortality was determined to be poor due to lack of clarity and the limited number of studies reporting mortality as an outcome. ConclusionImproved water supply interventions and sanitation uptake improves health. An expanded WaSH response in fighting HIV amongst infants is critical to prevent multiple opportunistic infections that can accelerate mother to child transmission of the virus and rapid disease progression.RegistrationThe protocol was published in the PROSPERO database with registration number CRD42021240512.