Tropical Health Matters

The Council of Anglican Provinces of Africa (CAPA) has a strategic 5-year plan for integrating its work on HIV/AIDS, TB and Malaria. Some aspects for the rationale for an integrated approach include the following:

• Control of all three diseases is affected by the same overall quality of care issues including infrastructural and human resource needs
• Faith based organizations have the ability to reach communities and individuals impoverished and affected by all three diseases through their health services and parish programs
• Pastoral care does not distinguish people by the diseases they have, but sees them as whole persons

Specifically for the Anglican community, CAPA explained that, “The Church is uniquely positioned with the ability to reach out to communities through her organized network and constituencies. CAPA through her structure is able to reach over 40 million regular and faithful members of the Church in Africa through different gatherings that are routinely conducted on daily, weekly, monthly and yearly basis using her vast human resource (skilled and unskilled Priest and Volunteers) and institutions.”

Other groups have recognized the value of integration. The Global Fund sees its Health System Strengthening component as an integrated way of addressing institutional bottlenecks that threaten control of all three diseases, as does WHO. Some grant supported programs, such as in Swaziland, already aim to strengthen the integration of TB and HIV/AIDS services.

Treatment of people and communities in a holistic way is an important goal, and may even achieve greater efficiencies and strengthen health systems to provide a greater range of quality services, not just support vertical programs.

Brahmbhatt et al., have just reported that, “Placental malaria increases the risk of MTCT after adjustment for viral load.” They likewise found that, “HIV-positive mothers with serological ICT (rapid immunochromatographic test) malaria were significantly more likely to have low-birth-weight infants, and low-birth-weight infants had significantly higher risk of MTCT compared with infants of normal birth weight.” The following conclusion was offered: “Programs should focus on enhanced malaria prevention during pregnancy to decrease the risk of adverse birth outcomes and MTCT.” The study took place in Rakai, Uganda using data gathered from 1994-2000, and the authors did caution that different results reported in other studies could be due to epidemiological differences in different settings.

Coincidentally and unfortunately we just shared with our readers the results of another study and recent DHS results from Uganda showing how poorly pregnant women are being protected from malaria. The women in Rakai study community had been monitored during the prenatal and postnatal periods, and in the present day would be more likely to benefit from preventive malaria interventions than those in the general population where stock supply and health personnel problems would be more serious.

These findings reinforce the need to integrate malaria in pregnancy control services such that maternal and child health and programs and the national malaria control programs actually work together to reach this important segment of the population at risk for malaria.

The added message is the need for better coordination between HIV and Malaria programs. Services for HIV positive women must ensure that they get LLINs and IPTp (unless receiving cotrimoxazole prophylaxis) not only to protect their own health, but also to prevent HIV transmission to their infants. When Round 8 Global Fund grant proposals come in for review, such program linkages should be be clearly emphasized. Current efforts to coordinate between PEPFAR and PMI could serve as a model.

Both Ghana and Nigeria received attention in the Press during the past week because of U.S. foreign assistance. The President’s Malaria Initiative (PMI) launched its activities in Ghana (one of 15 countries receiving PMI support) under the theme “Let’s Come Together and Drive Malaria Away.” Reports estimate that Ghana with an estimated population of approximately 23 million will receive around $US 6 million annually over the next three years from PMI. We congratulate their efforts.

Nigeria also made the headlines when President Yar’Adua visited the White House. The US President observed that Mr. Yar’Adua “is strongly committed to helping the Nigerian families affected by these diseases (HIV and malaria) get treatment and help.” The US pledged more funding for HIV, not malaria in this country of 140 million. Nigeria has received less than $US 3 million annually for malaria activities as a ‘non-focus’ country as regards PMI.

Reports noted that Nigeria has the third highest number of HIV cases in the world, which is seen as justification for continued HIV support, even though targets have not been achieved. Due to its sheer size and its location in a Plasmodium falciparum endemic zone, Nigeria is also likely to have the one of the highest number of malaria cases and the highest number of malaria deaths, too.

Nigeria met all criteria for inclusion in the PMI effort except for one fact, its population. PMI’s goal of covering 15 countries with a total population of 170 million could not have accommodated Nigeria. This is not to say Nigeria lacks malaria support. One of PMI’s criteria was that other donors, especially GFATM, be present in a country so that PMI’s efforts could be complimentary and make scale up even faster.

Nigeria is not without external support. It has some GFATM money, but this covers only half of the 37 states/territories and aims at supporting only a portion of local intervention efforts, not achieving full coverage targets alone. Apparently the GFATM has used Nigeria’s teething problems on these early grants to deny additional funding for the past three Rounds. There is the World Bank Booster program which has been quite slow in rolling out and targets another seven states. Advance plans are underway for DfID to contribute to malaria programming in an undisclosed number of states.

One is also right to ask about the amount of internal funding for malaria is provided by this oil rich country. Still, if the issue is massive scale up of malaria interventions, all partners, national, private, bilateral and international need to increase their support to control malaria in Nigeria.

A Los Angeles Times article on HIV/AIDS funding, particularly by the Gates Foundation and through the Global Fund to fight against AIDS, TB and Malaria (GFATM), has sparked a furor. The authors question whether the large and focused support for one disease reduces support for basic health systems issues and needs including nutrition, staffing, other infectious diseases and essential supplies and equipment.

An internal brain drain is described wherein staff migrate to HIV-related positions that attract supplemental salary. What could be termed replacement mortality is discussed when people survive HIV because of ART (anti-retroviral therapy) but die of other diseases because they are poor and malnourished. It is not a pretty picture.

Responses have been strong with some criticizing the audacity of the authors to question the good will of the donors while others questioning the academic and scientific qualifications of the donors to make intelligent decisions about channeling aid. Overall it is interesting that the malaria portion of such funding appears to have escaped the most scathing complaints.

When the Roll Bank Malaria Partnership got underway in 1998 one of the key components of discussion was the premise that malaria control must be pursued in the context of health system reform. The assumption was that all major malaria interventions required a strong health system for their effective delivery. Malaria care was already part of Integrated Management of Childhood Illness (IMCI). We certainly haven’t heard of special malaria clinicians receiving salary supplements for dispensing ACTs.

We are aware, as is the GFATM that one of the major problems in delivering malaria interventions are basic health systems bottlenecks such as weaknesses in forecasting and procurement, supply chain disruptions and inadequate dissemination of current malaria care policies and guidelines to frontline health staff. What was not mentioned in the Los Angeles Times article is that GFATM encourages countries to include ‘Health System Strengthening’ components in their proposals, although this has not been a major component to date.

Finally we are also aware as we have recently shared that malaria prevention efforts have positive benefits on nutritional status. Use of bednets/ITNs has helped reduce all cause infant and child mortality. Are we herein defending the special attention being given to malaria after years of neglect? Maybe readers would like to comment from their own experiences?

The recent announcement that global HIV/AIDS estimates were in over six million cases lower [http://www.nytimes.com/2007/11/20/world/20aids.html] is probably not a cause for celebration on World AIDS Day since those who actually are affected and infected still suffer. According to the New York Times, “In only a few countries, such as Kenya and Zimbabwe, do the figures reflect widespread behavioral changes, such as decisions by many people to have sex with fewer partners.” The rest of the reduction is due to changes in the way the estimates were calculated. Now Nigeria and South Africa top the list with the most people living with HIV/AIDS. The fact that a large portion of those who suffer also live in malaria endemic areas, is cause for further concern.

CBS News HealthWatch of 24 October 2007 posted the news that, “Malaria is fueling the spread of AIDS in Africa by boosting the HIV in people’s bodies for weeks at a time, says a study (by University of Washington researchers reported in Nature) that pins down the deadly interplay between the dual scourges. It’s a vicious cycle as people weakened by HIV are, in turn, more vulnerable to malaria.” (http://www.cbsnews.com/stories/2006/12/07/ap/health/)

Recent studies have shown that there is need to combine efforts in malaria control and HIV/AIDS management to save lives. Kamya et al. (AIDS 2007; 21:2059-2066) reported from Uganda that a combination of prophylaxis with Trimethoprim-sulfamethoxazole and insecticide treated bednets was associated with “a dramatic reduction in malaria incidence among HIV-infected children.” Similar results had been found with adults.

Also in Uganda a study by Malamba et al. concluded that, “HIV-infected children with severe malarial anemia suffered higher all-cause mortality and malaria-related mortality than HIV-uninfected children. Children with HIV and malaria should receive aggressive treatment and further evaluation of their HIV disease, particularly with regard to cotrimoxazole prophylaxis and antiretroviral therapy.” (http://www.malariajournal.com/content/6/1/143)

Distribution of ITNs to people living with HIV/AIDS is underway in a number of PEPFAR supported programs. More collaborative efforts are needed between malaria, HIV and MCH programs, and countries need joint planning for HIV and malaria control when preparing and implementing their Global Fund grants.

The US Embassy in Tanzania has announced a donation of about 50 insecticide-treated nets to HIV/AIDS orphans. While this is a relatively small effort, it sets a good example for possible synergies between HIV and Malaria programming and funding.

The attached map from WHO shows the geographical overlap of the two diseases. According to WHO’s Global Malaria Program, “The resulting co-infection and interaction between the two diseases have major public health implications.

• HIV-infected people must be considered particularly vulnerable to malaria;
• Antenatal care needs to address both diseases and their interactions;
• Where both diseases occur, more attention must be given to specific diagnosis for febrile patients.”

It is important therefore that ITNs are not only given to orphans, but all HIV infected people, particularly pregnant women. Malaria enhances transmission of HIV to the child, and therefore ITNs are an important component of PMTCT. Therefore, all donor programs that have both malaria and HIV components need to plan together to serve those in need and not think only in vertical control paradigms.

PS – Thanks for your support and interest. This is our 100th malaria blog.

Malaria and HIV overlap in much of Africa. In 2004 WHO held discussions about potential interactions between HIV and malaria. At that time the technical group found there was need for more research to determine if there were any interactions of any magnitude between HIV drugs and artemether, lumefantrine or quinine.

Two recent reports address HIV and Malaria drug interactions. German et al. published a brief correspondence entitled, “Hepatotoxicity Due to a Drug Interaction between Amodiaquine (AQ) plus Artesunate and Efavirenz.” Parikh et al. have also suggested potential problems. “Considering drugs likely to be coadministered with AQ, the antiretroviral drugs efavirenz, saquinavir, lopinavir, and tipranavir (could inhibit AQ metabolism and) may have important clinical implications for the efficacy and toxicity of AQ.” Meanwhile, Kokwaro and colleagues indicate that the jury is still out on interactions between artemether-lumefantrine and antiretrovirals.

Bretlinger et al. express concern that “Standard clinical guidelines do not reflect the full complexity of the interactions and overlaps between the 2 infections” because of their “vertical” nature. Now that more is becoming known about HIV-Malaria interactions generally and drug interactions specifically, the time for integrated disease management guidelines is upon us. WHO and partners like GFATM, US Government (PMI, PEPFAR) and World Bank, among others need to come together and develop an integrated approach to researching, funding and fighting these two diseases.

The Global Fund to fight Against AIDS, TB and Malaria (GFATM) has to date awarded only about one-quarter of its resources to malaria grants. A new publication entitled Partners in Impact Results Report from GFATM summarizes key activities and performance up through December 2006. There may be some argument about the relative cost of HIV versus Malaria interventions, but as we see from further analysis of grant performance, malaria grants could benefit from more funding to address health systems issues that challenge good performance.

The first two charts seen here summarize concerns presented in the 2007 Results Report. As of December 2006, 215 grants had reached Phase 2 renewal status. A smaller proportion of malaria grants have achieved the higher status “A” and “B1” classifications concerning performance than HIV or TB grants. Furthermore, when one compares grant performance against targets set by the grants themselves, once can see that Malaria Interventions (ACT and ITN distribution) are less likely to achieve their targets than HIV (ARV distribution and Counseling & Testing, for example) ot TB (DOTs). Clearly Malaria Grant recipients need additional funds and technical assistance to improve their performance.

This brings up another interesting issue. The Results Report also summarizes performance by type of Principal Recipient. NGOs and Civil Society Organizations receive 30% of funding but according to the third chart below, their grant performance is better than government agencies or the UNDP. Although a direct connection cannot be made from the data in the report, this finding suggests that Malaria Grants might benefit from greaer involvement from the NGO sector. In the meantime, technical assistance for malaria grants is needed not only for developing better proposals in Round 7, but more importantly for ensuring that the existing grants perform better and thus justify continued malaria investments in those countries.

Last year EM Kamau wrote about “the enormous potential that exists between (the HIV and the Malaria) initiatives that seek to address closely related issues and targeting the same populations at risk within a fairly well defined geographical setting”  in the African Journal of Health Sciences. These synergies are not always found in practice. The HIV/AIDS project of the Nigerian NGO Mothers’ Welfare Group targets orphans and/or children affected by HIV. They provide specialized VCT for children and young adolescents and medical care for opportunistic diseases such as malaria. Even though they are working in Kaduna State, which receives support from the Nigeria’s Global Fund Malaria grant, they have found difficulty in obtaining ACTs and ITNs for the vulnerable and HIV-infected children in their care.

The US President’s HIV/AIDS program, PEPFAR, does talk about the need to provide malaria services for people affected by HIV. “PEPFAR-supported interventions to optimize survival of HIV-exposed and -infected children include provision of basic preventive care, including support for infant and young child nutrition, immunizations and prevention of infections such as malaria, tuberculosis, and pneumonia. The pediatric preventive care package includes life-saving interventions, such as cotrimoxazole prophylaxis to prevent opportunistic infections, including diarrheal disease; screening for tuberculosis and malaria; prevention of malaria using long-lasting insecticide-treated mosquito nets; and support for nutrition and safe water.” Under PEPFAR pallitive care shoud include “Provision of the following drugs and commodities: cotrimoxazole; isoniazid; insecticide-treated bed nets; point-of-use water treatment and safe-water storage vessels; soap; and hand – washing instructions for HIV-exposed and -infected children.” PEPFAR even sets reportable indicators around malaria: “PEPFAR indicators for palative care include: Number of service outlets/programs providing malaria care and/or referral for HIVinfected clients (diagnosed or presumed) as part of general HIV-related palliative care. This number is a subset of the number of service outlets/programs providing general HIV-related palliative care.”

Conversely, the US President’s Malaria Initiative acknowledges the need to target PLWHAs as a vulnerable group in malaria prevention and control. As seen in the PMI country action plan for Uganda, “This will be achieved by reaching 85% coverage of the most vulnerable groups-children under five years of age, pregnant women, and people living with HIV/AIDS-with proven preventive and therapeutic interventions, including artemisinin-based combination therapies (ACTs), insecticide-treated nets (ITNs), intermittent preventive treatment (IPT) of pregnant women, and indoor residual spraying (IRS).”

PEPFAR and PMI program planners are consciously thinking about the synergistic possibilities in addressing malaria in HIV.  Other donor efforts and national disease control programs should collaborate more on these two crucial health problems.

George Parris wrote recently in Medical Hypotheses about the likelihood that a malaria medicine trial of pamaquine/plasmoquine in Leopoldville (Kinshasha) in 1927 basically interfered with the work of an existing retrovirus that may have actually helped primate T-cells attack the liver stage of the malaria parasite, and hypothesized that later use of chloroquine exacerbated the problem. Please read the article for the technical details. Based on this analysis, he discounts the common zoonotic hypotheses of the origins of HIV.

If this hypothesis proves true, it is only fitting that the Global Fund addresses both HIV and Malaria, but should do so in equal measure now that new non-chloroquine antimalarial drugs are being promoted. In addition many studies exsit to show the negative synergies between HIV and Malaria. Laufer and Plowe suggest that the effect of malaria infection on HIV disease progression due to increased viral replication may be important and needs to be fully explored. Desai et al. report that HIV increases the risk of malaria and its adverse effects in pregnant women. In a review of recent research Slutsker and Marston state that HIV-infected persons are at increased risk for clinical malaria; the risk is greatest when immune suppression is advanced. They also note that adults with advanced HIV may be at risk for failure of malaria treatment, especially with sulfa-based therapies, and that malaria is associated with increases in HIV viral load that, while modest, may impact HIV progression or the risk of HIV transmission.

Clearly we cannot undo the past, but it is incumbent on countries where both HIV and Malaria coexist to plan integrated and conprehensive approaches to managing both diseases