Category Archives: HIV

AIDS and Malaria: The Challenge of Co-Infection Persists

While the International AIDS Society is holding its 2015 meeting in Vancouver, it is important to remember that individual infectious diseases do not exist in isolation, but in combination make life worse for infected people. The co-infective culprit with HIV/AIDS that usually received the most attention is Tuberculosis, but malaria is not without its dangers. Herein we highlight a few recent studies and publications on the interactions between HIV and malaria.

Just because today malaria is primarily a tropical disease, it does not mean that people living with AIDS (PLHIV) in other parts of the world are not at risk. Schrumpf and colleagues point out that people living with HIV frequently travel to the tropics and thus may be at risk of infection by one of the species of malaria parasite. PLHIV are not unlike other travelers who do not always adhere with travel recommendations for using bednets and taking appropriate prophylaxis, but the consequence of non-adherence may be more severe.

In areas endemic for both malaria and HIV the effects of co-infection continue to be studied.  In westernDSCN6373 Kenya Rutto and co-workers report that, “HIV-1 status was not found to have effect on malaria infection, but the mean malaria parasite density was significantly higher in HIV-1 positive than the HIV-1 negative population.” So do malaria prevention and treatment interventions mitigate any of these problems?

Co-infection is not the only shared problem of these two diseases in areas where both are endemic. Yeatman et al. reported that, “In malaria-endemic contexts, where acute HIV symptoms are commonly mistaken for malaria, early diagnostic HIV testing and counseling should be integrated into health care settings where people commonly seek treatment for malaria.”

Mozambique has updated its guidelines for managing anemia among HIV-infected persons. The updated “guidelines for management of HIV-associated anemia prompts clinicians to consider opportunistic conditions, adverse drug reactions, and untreated immunosuppression in addition to iron deficiency, intestinal helminthes, and malaria.” Brentlinger and colleagues concluded that the guidelines are valuable in helping clinicians address anemia through a variety of interventions.

In areas where anti-retroviral treatment may be delayed, use of long lasting insecticide treated nets (LLINs) might help. Again in Kenya, Verguet and fellow researchers conducted a cost analysis and concluded that, “Provision of LLIN and water filters could be a cost-saving and practical method to defer time to ART eligibility in the context of highly resource-constrained environments experiencing donor fatigue for HIV/AIDS programs.”

Introduction of universal cotrimoxazole prophylaxis for all HIV positive patients in Uganda is seen to have a positive effect on reducing malaria infections among HIV positive patients. Rubaihayo and research partners found this effect as well as reported on several other studies with similar results.

One key overall lessons from these studies is the need to have integrated services for prevention, detection and management of both malaria and HIV. National health programs as well as global donors should make integrated service delivery a priority.

Update on Malaria and HIV/AIDS

63719_10152358606695936_7047535049294543967_nWorld AIDS Day is a time to reflect on the broader impact of HIV and its interactions with other infectious and chronic conditions that must be managed through an integrated health system. The past few months have yielded a variety of published studies on the HIV-Malaria link ranging from pharmacological, and physiological to health systems issues. A brief summary follows.

Having HIV does have consequences on malaria infection. Serghides et al. studied malaria-specific immune responses are altered in HIV/malaria co-infected individuals. Fortunately these researchers learned about “the importance of HIV treatment and immune re-constitution in the context of co-infection.”

Malaria, HIV and Pregnancy

Pregnant women are an important group in the population to protect from both HIV and malaria. The link between the diseases may not be one of influencing each other but in the fact that they both appear in the same population with similar negative consequences. Women are at increased risk of anemia in pregnancy due to malaria and/or HIV infection according to Ononge and co-workers. Normally a pregnant woman in a malaria endemic area passes on malaria antibodies to their newborns.

Moro et al. learned that, “Placental transfer of antimalarial antibodies is reduced in pregnant women with malaria and HIV infection.” Chihana and colleagues studied HIV status in Malawian pregnant women and follow-up their children. They reported that, “Maternal HIV status had little effect on neonatal mortality but was associated with much higher mortality in the post-neonatal period and among older children.”

Drug Interactions and Issues

Hoglund and colleagues studied interactions between common antimalarial and HIV medications. They found that, “There are substantial drug interactions between artemether-lumefantrine and efavirenz, nevirapine and ritonavir/lopinavir. Given the readily saturable absorption of lumefantrine, the dose adjustments predicted to be necessary will need to be evaluated prospectively in malaria-HIV coinfected patients.”

DSCN4994 AngolaDrugs taken during pregnancy to prevent malaria are influenced by HIV status. It is known that Intermittent Preventive Treatment with sulfadoxine-pyrimethamine should not be administered to HIV-positive pregnant women taking cotrimoxazole prophylaxis. González et al. wanted to learn whether mefloquine (MQ) could be used by HIV+ pregnant women. Unfortunately they learned that, “MQ was not well tolerated, limiting its potential for IPTp … (and) … MQ was associated with an increased risk of mother to child transmission of HIV.”

Health Systems Issues

Haji and co-investigators reported that malaria care seeking was delayed in Ethiopia because “Children whose guardians believed that covert testing for HIV was routine clinical practice presented later for investigation of suspected malaria.”

The need to adjust clinical guidance and practice as prevalence of malaria changes was addressed by Mahende et al. in Tanzania. They observed that, “Although the burden of malaria in many parts of Tanzania has declined, the proportion of children with fever has not changed.” More accurate diagnosis is needed as demonstrated by the various causes of febrile illness they found including in addition to malaria, respiratory illnesses, blood infections, urine infections, gastrointestinal illness and even HIV.

Finally Mbeye and colleagues report that cotrimoxazole prophylactic treatment reduces incidence of malaria and mortality in children in sub-Saharan Africa and appears to be beneficial for HIV-infected and HIV-exposed as well as HIV-uninfected children. This lesson from HIV programming can have broader implications for malaria control strategies.

Integrated control of infectious diseases is essential for population health, especially at the primary care level. Hopefully research as shown above can assist in planning better services for people living in areas that are endemic to both malaria and HIV.

Malaria at AIDS2014

Malaria and HIV/AIDS interact on several fronts from the biological, clinical, pharmacological to the service delivery levels.  The ongoing 20th International AIDS Conference in Melbourne, Australia (July 20-25, 2014) provides an opportunity to discuss some of these issues. Abstracts that are available as of 20th July are mentioned below and deal largely with integrated health service delivery issues. Details can be found at http://www.aids2014.org/. Also keep up to date on twitter at https://twitter.com/AIDS_conference, and on Facebook at https://www.facebook.com/InternationalAIDSConference.

8577_760104147337737_5024191_n1. Increasing HIV testing and counseling (HTC) uptake through integration of services at community and facility level (TUPE358 – Poster Exhibition). E. Aloyo Nyamugisa, B. Otucu, J.P. Otuba, L. Were, J. Komagum, F. Ocom, C. Musumali (USAID/NU-HITES Project, Plan International – Uganda, Gulu, Uganda).

HTC integration at community outreaches and facility service points increases service uptake by individuals, families and couples that come to access the different services that are offered concurrently such as immunization, family planning, cervical cancer screening, circumcision, Tuberculosis, malaria, nutrition screening services and other medical care.

2. Asymptomatic Malaria and HIV/AIDS co-morbidity in sickle cell disease (SCD) among children at Mulago Hospital, Kampala, Uganda (TUPE074 – Poster Exhibition). B.K. Kasule, G. Tumwine, (Hope for the Disabled Uganda, Kampala, Uganda, Watoto Child Care Ministries, Medical Department, Kampala, Uganda, Makerere University, College of Veterinary Medicine, Animal Resources & Bio-security, Kampala, Uganda).

The prevalence of HIV/AIDS and asymptomatic malaria in children attending SCD clinic were quite high with the former exceeding the national prevalence supporting the view than Ugandan children with SCD die before five years. Children were significantly stunted and underdeveloped which could have made them prone to increased clinic visits. National health programmes should focus on the health needs of children with SCD by integrating HIV/AIDS care, nutritional therapy, and malaria control programmes.

3. Technical support (TS) needs of countries for preparation of funding requests under the Global Fund’s new funding model (NFM) (THPE427 – Poster Exhibition). A. Nitzsche-Bell, B. Hersh (UNAIDS, Geneva, Switzerland).

The results of this survey suggest that there is very high demand GF funding in 2014 and a concomitant high demand for TS to assist in the preparation of funding requests. TS priority needs span across different technical, programmatic and management areas. Increased availability of funding for TS and enhanced partner coordination through the Country Dialogue process are needed to ensure that countries have access to timely, demand-driven, and high-quality TS to maximize mobilization of GF resources under the NFM.

4. Optimizing the efficiency of integrated service delivery systems within the existing scaled-up community health strategy in Kenya: pathfinder/USAID/APHIAplus Nairobi-Coast program experience (THPE351 – Poster Exhibition). V. Achieng Ouma, D.M. Mwakangalu, P. Eerens, J. Mwitari, E. Mokaya, J. Aungo Bwo’nderi, S. Naketo Konah (Pathfinder International, Nairobi, Kenya, Pathfinder International, Service Delivery, Mombasa, Kenya, Ministry of Health, Division of Community Health Strategy, Nairobi, Kenya, Pathfinder International, Research and Metrics/Strategic Information Hub, Nairobi, Kenya, University of Portsmouth, Geography, Portsmouth, United Kingdom).

APHIAplus (a USAID sponsored health program in Kenya) supports the implementation of integrated government strategies that center around HIV, AIDS, and tuberculosis prevention, treatment, and care; integrated reproductive health and family planning services; and integrated malaria prevention and maternal and newborn health services. Lessons learned include the finding that integrated outreach holds potential to meet clients’ needs in an efficient, effective manner. For example, during a single contact with a service provider, a mother obtains immunization services and growth monitoring for her infant, counseling and testing for HIV, counseling on family planning, cervical cancer screening, and treatment of minor ailments. Results indicate better integration of HIV prevention, care, and treatment within complementary efforts that address key drivers of mortality and morbidity. Success in integration was fostered by a stronger focus on outcomes throughout the APHIAplus implementation cycle.

5. Long term outcomes of HIV-infected Malawian infants started on antiretroviral therapy while hospitalized (THPE070 – Poster Exhibition). A. Bhalakia, M. Bvumbwe, G.A. Preidis, P.N. Kazembe, N. Esteban-Cruciani, M.C. Hosseinipour, E.D. Mccollum (Albert Einstein College of Medicine and Children’s Hospital at Montefiore, Pediatrics, Bronx, United States, Baylor College of Medicine Abbott-Fund Children’s Clinical Centre of Excellence, Lilongwe, Malawi, Baylor College of Medicine, Pediatrics, Houston, United States, University of North Carolina Project, Lilongwe, Malawi, Johns Hopkins School of Medicine, Pediatrics, Division of Pulmonology, Baltimore, United States).

AIDS2014 bannerOne-year retention rates of HIV-infected infants diagnosed and started on ART in the hospital setting are comparable to outpatient ART initiations in other Sub-Saharan countries. Further studies are needed to determine if inpatient diagnosis and ART initiation can provide additional benefit to this population, a subset of patients with otherwise extremely high mortality rates.  Of the 16 children who died, median time from ART initiation to death was 2.7 months. Causes of death include pneumonia, diarrhea, fever, anemia, malnutrition, malaria and tuberculosis.

6. Killing three birds with one stone: integrated community based approach for increasing access to AIDS, TB and Malaria services in Oyo and Osun States of Nigeria (MOPE435 – Poster Exhibition). O. Oladapo, E. Olashore, K. Onawola, M. Ijidale. (PLAN Health Advocacy and Development Foundation, Programs, Ibadan, Nigeria, Civil Society for the Eradication of Tuberculosis in Nigeria, Programs, Ibadan, Nigeria, Community and Child Health Initiative (CCHI), Programs, Ibadan, Nigeria, Community Health Focus (CHeF), Programs, Ibadan, Nigeria).

Community Systems Strengthening (CSS) is a tested and successful strategy for providing integrated AIDS, TB and Malaria (ATM) services in resource-limited settings. 20 selected community based organizations (CBOs) working on at least one of AIDS, TB or Malaria were trained by PLAN Foundation on basics of ATM-related project management including monitoring and evaluation; demand generation through active referrals; and community outreaches. Empowering CBOs is an effective and low-cost strategy for increasing demand for ATM services in resource-limited settings. Integrating referral for ATM services increases effectiveness of and public confidence in primary healthcare services at the grassroots.

7. (Upcoming on 21st July) The health impact of a program to integrate household water treatment, hand washing promotion, insecticide-treated bed nets, and pediatric play activities into pediatric HIV care in Mombasa, Kenya (MOAE0104 – Oral Abstract Session). N. Sugar, K. Schilling, S. Sivapalasingam, A. Ahmed, D. Ngui, R. Quick. (Project Sunshine, New York, United States, U.S. Centers for Disease Control and Prevention, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infections, CDC, Atlanta, United States, New York University, New York, United States, Bomu Hospital, Mombasa, Kenya).

Don’t Forget Malaria on World AIDS Day

logo-wad2World AIDS Day coming up on Sunday 1 December 2013 is not just a time to think about progress and challenges of one infectious disease, but the interaction between HIV and other infections, especially Malaria.  Adu-Gyasi and colleagues express the relationship well in their article on malaria among HIV patients in Ghana: “Malaria is associated with an increase in HIV viral load and a fall in CD4-cell count. Conversely, HIV infection disrupts the acquired immune responses to malaria and the efficacy of antimalarial drugs.” Recent research provides continued insight that we must look at the two diseases as a joint problem in malaria endemic regions.

Research was conducted on mice that were infected with P. chabaudi malaria. The mice showed increased gut and genital mucosal T cell immune activation and HIV co-receptor expression. The implication of the findings was that malaria infection might enhance the sexual acquisition of HIV in humans, and the authors recommended further research to learn more.

In another study researchers looked at Malaria and HIV co-infection and their effect on haemoglobin levels from three health-care institutions in Lagos, Nigeria. The data showed that the total number of malaria infected patients were significantly higher in HIV sero-positive patients 47.7% (31/65) when compared with their HIV sero-negative counterparts 25.8% (262/1015) P = 0.047.  Not only was there a higher prevalence of malaria in HIV infected patients but also patients co-infected with malaria and HIV were more likely to be anaemic.

DSCN4965smBoth HIV and malaria in pregnancy present serious problems. Another recent study looked at Cotrimoxazole (CTX) prophylaxis versus mefloquine (MQ) intermittent preventive treatment (IPT) to prevent malaria in HIV-infected pregnant women. The study concluded that, “CTX alone provided adequate protection against malaria in HIV-infected pregnant women, although MQ-IPTp showed higher efficacy against placental infection. Although more frequently associated with dizziness and vomiting, MQ-IPTp may be an effective alternative given concerns about parasite resistance to CTX.”

Concern about malaria and HIV in pregnancy also focuses on the child. Research examined malaria diagnosis in pregnancy in relation with early perinatal mother-to-child transmission (MTCT) of HIV.   The authors reported that “HIV MTCT risk increased by 29% (95% CI 4-58%) per MIP episode. Infants of women with at least two vs. no MIP diagnoses were 2.1 times more likely to be HIV infected by 6 weeks old (95% CI 1.31-3.45).”

Finally since concurrent experience of both malaria and HIV infections means taking multiple drugs, researchers have also looked at the potential challenges of drug interaction. “An extensive literature search produced eight articles detailing n = 44 individual pharmacokinetic interactions.”  While various HIV medications either increased or decreased the exposure to malaria drug components including lumefantrine and artemisinin, artemether-lumefantrine or artesunate combinations generally had little effect on the pharmacokinetics of HIV-antivirals (with two exceptions).

It is difficult to say which disease is closer to reaching elimination goals, but unless both are understood from their mutual impacts on transmission and treatment of the other, both will continue to elude control efforts.

Integration: Malaria at the International AIDS Conference

The International AIDS Conference in Washington, DC, this week is attracting major media attention daily. The implications of the presentations go beyond one disease and address important health systems issues. Those presentations that address both HIV/AIDS and other infectious diseases like malaria are of particular interest when considering integration as part of health systems strengthening.

Integration in Service Delivery

Gebru and colleagues share experiences from Ethiopia. Community health extension workers integrated services at the household and showed that, “Integrating malaria program with HIV/AIDS at community level has brought health benefits among PLHIV. We have learned this project it is cost effective and advances efficient use of human and material resources. We also learnt that insuring active participation and involvement of HIV infected people is very instrumental for successful integration of Malaria activities with HIV care and support program.”

dscn7279sm.jpgEfforts to re-energize integrated clinical care in Zambia were presented by Mugala et al. With PEPFAR support they expanded enrollment, conducted mobile outreach and ensured that HIV, malaria and other maternal health services were integrated throughout the district.

Researchers in Kenya reported on provision of integrated preventive services to people living with HIV/AIDS and noted that, “The provision of LLIN and a water filter in the context of routine HIV care is associated with a significant delay in C D4 decline and represents a simple, practical and cost-effective method to delay HIV-1 progression in many settings.”

Integration in Diagnostics

A Ugandan experience with integrated community HIV testing campaigns was shared by Chamie et al. A 5-day campaign provided point of care screening for HIV, malaria, TB, hypertension and diabetes. They were able to reach 74% of the adult population, found undiagnosed conditions and proved the feasibility of integrated testing.

Echete and co-workers shared experiences in strengthening rural health center laboratories in Ethiopia. Lab staff were trained on HIV, TB, and malaria diagnosis and received follow up supervision and performance checks. While they found integrated laboratory services could be brought to remote areas, they also cautioned on the need to guarantee sustainability.

From these few examples, we can see that integration helps improve quality of care, ability to reach out to communities and even improves quality of life for community members.  More operational research is needed to identify additional synergies that arise from integrating and malaria services.

Professor Onwuliri’s Contribution to Malaria Research

farewell2.jpgThe recent fatal crash of Dana Air in Lagos, Nigeria claimed the life of a renown parasitologist and educator, Professor C.O. Onwuliri, most recently the Vice Chancellor of the Federal University of Technology Owerri. In his remembrance we are sharing the abstracts of two recent malaria publications of which he was a co-author. His various publications also focus on onchocerciasis, lymphatic filariasis and other parasitic diseases.

Perceptions on the use of insecticide treated nets in parts of the Imo River Basin, Nigeria: implications for preventing malaria in pregnancy. Chukwuocha UM, Dozie IN, Onwuliri CO, Ukaga CN, Nwoke BE, Nwankwo BO, Nwoke EA, Nwaokoro JC, Nwoga KS, Udujih OG, Iwuala CC, Ohaji ET, Morakinyo OM, Adindu BC. Afr J Reprod Health. 2010; 14(1): 117-28.

ABSTRACT: This study aimed at assessing perceptions on use of ITNs in parts of the Imo River Basin, Nigeria and its implications in preventing malaria in pregnancy. Data was collected using focus group discussions, key informant interviews and structured questionnaires. Results showed high awareness on the benefits of ITNs. Factors affecting use of ITNs included its high cost, perceptions of chemicals used to treat them as having dangerous effects on pregnancy, low utilization of antenatal care, husband’s lack of interest in malaria prevention and perceptions  that adolescent girls are at low risk of getting malaria. The implications of these findings include demystifying the negative perceptions on the chemicals used for net treatment and subsidizing the cost of ITNs to increase access. These findings provide important lessons for malaria programmes that aim at increasing  access to ITNs by pregnant women in developing countries.

Malaria infection in HIV/AIDS patients and its correlation with packed cell volume (PCV). Goselle ON, Onwuliri CO, Onwuliri VA. J Vector Borne Dis. 2009; 46(3): 205-11.

OBJECTIVES: The study was designed: (i) to determine the prevalence of malaria parasites; (ii) to determine the relationship between parasitaemia and age/sex; (iii) to correlate the PCV levels with parasitaemia; and (iv) to determine the influence of protection against natural transmission on the prevalence of malaria.

METHODS: Participants were recruited at the Plateau State Human Virology Research Laboratory (PLASVIREC), Robert Gallo House at the Plateau State Specialist Hospital, Jos and grouped into: (i) Malaria and HIV co-infection group (n = 64);  and (ii) HIV infected group without concurrent malaria infection (n = 136). Standard laboratory procedures were used for the HIV and Plasmodium parasites screening, malaria parasite density, and packed cell volume.

RESULTS: The results showed a significant difference (p >0.05) among the sexes and age groups. About 64 (32%) of the individuals had Plasmodium infection (30% Plasmodium falciparum, 0.5% P. malariae, and 1.5% mixed infections of P. falciparum and P. malariae). Malaria parasites were more common among the rural dwellers and in the age group of 21-30 yr. Regression analysis showed a negative  association of malaria parasitaemia and PCV among the malaria-HIV positive and malaria-HIV negative (r2 = 0.529; p < 0.001). CONCLUSION: In the present study, PCV might be of useful indicator and if not monitored could lead to AIDS establishment especially where  high malaria parasitaemia is noted. The findings further suggest that the defined stage of HIV infection in the study, malaria coinfection may moderate the impact  of HIV infection on PCV.

Lesson on World AIDS Day – don’t forget human behavior

This morning’s Washington Post featured a story concerning another setback in HIV/AIDS prevention research. The article stated that, “The abrupt closure last week of one part of a complicated study called VOICE marked the third time in eight months that anti­retroviral drugs did not prevent infection in those assigned to use them.” Ironically, the interventions had proven effective in smaller scale trials.  What happened during scale up?

logo-wad.jpgThe two research interventions focused on either having women insert a vaginal gel daily or people taking pills. One explanation offered for the failure the second time around was as follows:

The answers may lie in subtle differences between the groups being studied and the designs of the experiments. For example, the volunteers in Partners PrEP (pre-exposure prophylaxis study) were long-term couples in which one person was infected and the other not. It’s possible they may have been more motivated to take the pills every day. In CAPRISA (the South African PrEP study), the women inserted the vaginal gel before and after sexual intercourse rather than every day — a targeted approach that may have helped them stick to the program.

Such differences in the social and behavioral context of research make all the difference – basic research on drug effectiveness cannot be divorced from the people who receive the medications. The Post contacted experts who offered the following opinions about why there were problems.

  • The daily regimen just probably was not acceptable; if the gel were being used according to instructions some differences between groups should have emerged.
  • Other studies of vaginal microb­icides and pre-exposure prophylaxis have shown that few people use prevention tools as regularly as they say they do, but the more “adherent” people are, the more protection they get.
  • What we have to face up to is that everything in HIV prevention is based in human behavior.

The article concluded by saying, “What seems clear is that this strategy, once viewed as the easiest and most certain, is going to require a lot of fine-tuning even if it works.”

With malaria interventions, similar lessons apply. ACTs do not protect is people do not adhere to the 3-day regimen. LLINs do not protect if people use them to cover their vegetable gardens. IPTp is not effective unless pregnant women attend antenatal care regularly. Rapid diagnostic tests are wasted if health workers do not believe in their efficacy.

Often we wait until problems of non- or inappropriate utilization of health interventions occur before we start looking at social and behavioral factors. The Post quoted one epidemiologist who said, “People are upset. It’s a big head-scratcher as to why it didn’t work.” Researchers should be embarrassed to admit such, as this means they did not do adequate formative research in advance to understand the social and cultural context into which they were introducing their innovations.

Certainly similar mistakes have been made in malaria research and intervention, but now with international donor funding severely threatened, we cannot waste resources pushing interventions that are not socially and culturally acceptable.

Malaria and HIV 2010

Another World AIDS Day has come and passed. Sarah Boseley has commented on the information overload that comes this time of year on the disease and the range of basic health programming and valiant efforts to control it. This led to thoughts on whether there are any new developments concerning the connections between Malaria and HIV.

A quick look at the most recent PubMed listings for “Malaria AND HIV” mostly yielded sentences with the common theme of “AIDS, TB and Malaria” that considered the big disease funding efforts and the combined global burden of disease but few new insights on how each disease affects the other. Some interesting examples were uncovered.

On the biological side, Jiang and colleagues in the journal Vaccine (2010 Nov 23;28(50):7915-22) observed that, “Malaria and human immunodeficiency virus type 1 (HIV-1) infection overlap in many regions of the world.” Using mouse models they found that, “important implications for the development of a new form of bivalent vaccine against both HIV-1 and malaria.”

On the programming side, Lugada et al. examined how “Integrated disease prevention in low resource settings can increase coverage, equity and efficiency in controlling high burden infectious diseases,” in rural Kenya, and reported on a campaign that provided, “HIV counseling and testing, 60 male condoms, an insecticide-treated bednet, a household water filter for women or an individual filter for men, and for those testing positive, a 3-month supply of cotrimoxazole and referral for follow-up care and treatment.” (PLoS One. 2010 Aug 26;5(8):e12435)

Reid reported on how injections for suspected malaria cases in drug shops and stores Tanzania and other rural African settings sets the stage for HIV and other infections. The need to prevent such practices can help both diseases. (Rural Remote Health. 2010 Jul-Sep;10(3):1463)

Noting that, “Co-infection of human immunodeficiency virus (HIV) with malaria is one of the pandemic problems in Africa and parts of Asia,” Oguariri and co-investigators examined, “the impact of pyrimethamine (PYR) and two other clinical anti-malarial drugs (chloroquine [CQ] or artemisinin [ART]) on HIV-1 replication.” They showed that, “10 μM CQ and ART inhibited HIV-1 replication,” while “10 μM PYR enhanced HIV-1 replication.” This is important news for malaria case management in areas with high HIV prevalence. (Virus Res. 2010 Nov;153(2):269-76)

While these studies individually may not be earth-shaking, they do point to the continued need for partnership between Malaria and HIV control programs – common interests do exist together with the common desire to save lives.

PEPFAR Could Build Bridges to Malaria Programs

Under its new strategy, “PEPFAR patients will also be treated for tuberculosis, malaria and previously untreated tropical diseases,” according to a Washington Post editorial.  This is possible because, “PEPFAR 2 has three pillars: prevention, integration and improved health-care systems.”

pepfar.jpgThe Post further explains that with PEPFAR 2, “The goal is to make the services a routine part of each nation’s health offerings.” The Post quotes Eric Goosby, the U.S. global AIDS coordinator, as saying that, “We need to transition them into being more embedded in the countries’ infrastructure and for the countries to have true ownership of them.”

Research in Rakai, Uganda, has found, “Excellent self-reported retention and appropriate use of ITNs distributed as a part of a community-based outpatient HIV care programme. Participants perceived ITNs as useful and were unlikely to have received ITNs from other sources.” What PEPFAR 2 appears to be calling for is a more integrated systems approach that through the new US Global Health Initiatives that ensures that mothers, children and families get the full range of services they need from an improved and sustainable local health service.

Even before this greater focus on MCH, health professionals like Walensky and Kuritzkes, have noted the “massive direct and indirect benefits PEPfAR has achieved already for mothers and children. It may be that PEPfAR—by providing health infrastructure, HIV prevention, parental survival, and the opportunity to sustain economic growth.”  Though not stated directly, these views describe an environment that is also more favorable to malaria control.

There are those who see global health programs like PEPFAR and GFATM as “distracting governments from coordinated efforts to strengthen health systems and re-verticalization of planning, management and monitoring and evaluation systems.” Biesma et al. note that there is much more that donor programs “could do much more to promote country ownership through aligning their objectives with comprehensive national health.” The Washington Post editorial indicates that this is exactly where the new PEPFAR strategy is aiming.

World AIDS Day 2009 and Malaria

wad_logo.jpgThe UN Secretary General’s statement for the 2009 World AIDS Day reflects a theme common to the UN’s emphasis for malaria elimination – universal coverage. According to the Secretary General. “On World AIDS Day this year, our challenge is clear: we must continue doing what works, but we must also do more, on an urgent basis, to uphold our commitment to reach universal access to HIV prevention, treatment, care and support by 2010.”

091125_unhomephoto250x173.jpgUniversal coverage is reflected in this year’s theme, “Right to Health.” The right to health also means that those who live with HIV/AIDS in much of the tropical world also need access to health services that prevent and treat malaria because co-infection with the two diseases presents a greater threat to health and survival.

The research world has been grappling with the challenges of HIV and malaria co-infection as was in evidence during numerous presentations at the recently concluded MIM 5th Pan-African Malaria Conference in Nairobi.  A few of the many abstracts are excerpted below.

In Cameroon HIV/Malaria co-infection was more associated with … lower CD4+ counts, high parasitaemia, high fever frequency, longer illness duration and low Hb concentration (Theresa Nkuo-Akenji, et al., wifon@yahoo.com, MIM 2009 Abstract 388).

At Tororo District Hospital, Uganda a cross-sectional study of HIV-infected women taking TS prophylaxis and HIV-uninfected women taking IPT–SP (1:3 ratio) found that microscopic infection was associated with Low Birth Weight for all women, but
Submicroscopic (PCR) infection was associated with LBW only among HIV-uninfected women (Patrick M. Newman et al., patrick.newman@ucsf.edu, MIM 2009 Abstract 424).

For HIV-infected children in Kampala, Uganda, both AS/AQ and AL were highly efficacious. Compared to AL, AS/AQ was associated with a higher risk of neutropenia, anorexia, malaise and abdominal pain. In HIV-infected Ugandan children AL was safer and better tolerated than AS/AQ (Fredrick Kateera et al., fkkateera@yahoo.com, MIM 2009 Abstract 594).

malaria-and-hiv-at-mim-2009-sm.jpgFinally, Peter Ouma et al. (pouma@ke.cdc.gov, MIM 2009, Nairobi, Abstract 131) studied Peripheral Malaria Parasitaemia in Pregnant Women, Kenya. Their findings are seen in the graph to the right. Both cotrimoxizole and SP offered some protective effect for both HIV+ and HIV- women.

Please read the MIM abstracts for more current research on HIV and Malaria, and remember that universal coverage is a basic right, one that should help us re-visit commitments that were once made to ‘Health for All.’