Tropical Health Matters

On August 20, 2024, esaayman posted this blog about Hepatitis C in the class blog of the course, Social and Behavioral Foundations of Primary Health Care at the Johns Hopkins Bloomberg School of Public Health.

Hepatitis C remains a significant public health burden in South Africa, disproportionately affecting people who inject drugs, with the highest prevalences, monitored by the South African Community Epidemiological Network on Drug Use and the National Institute for Communicable Diseases, ranging from 68% to 94% in Tshwane. Despite national guidelines and an action plan for viral hepatitis recommending direct acting antiviral therapy and point-of-care technology use for hepatitis c management in people who inject drugs since 2019, with treatment registration by SAHPRA since 2020, access remains limited. The essential medicines list restricts treatment to tertiary level liver clinics. These clinics are often inaccessible to people who inject drugs due stigma, and stringent abstinence-based criteria for treatment.

_{Community hepatitis C screening at Sediba Hope Medical Centre (Source: SHMC, 2024)}

While community-based HIV-focused harm reduction services, such as opioid agonist therapy, exist, they are primarily managed by donor-funded civil society organizations, with limited integration into public healthcare systems. The City of Tshwane’s health department in partnership with the University of Pretoria initiated opioid agonist therapy services at primary care level in 2016, however with limited resources allocated, hepatitis c screening and treatment remains sporadic. A local pilot study, offered by Sediba Hope Medical Centre, a public-private partnership-based clinic for marginalized communities, has demonstrated successful community-based hepatitis c treatment integration, signalling for sustained access to care at the appropriate level.

_{HIV and viral hepatitis prevalence in South Africa (Source: INHSU, 2021)}

Improved access to treatment within the city would require purposeful implementation of hepatitis c treatment guidelines alongside best practices from harm reduction guidelines and national action plans. This includes training of primary care providers to manage uncomplicated cases, further supported by specialist through existing mentoring platforms. To strengthen clear referral pathways, collaboration between liver clinics and community-based harm reduction and primary care facilities is required, building on the use of existing inter-facility referral applications and decentralized medication delivery options. Additionally, dedicated funds for adequate diagnostic tools, care coordination staff, and medication procurement should be considered on a national level, with the same urgency as with the HIV response. By implementing these strategies, Tshwane can expand access to hepatitis c treatment for people who inject drugs, thereby aiming to become the first South African city to achieve micro-elimination, averting adverse health outcomes for people who inject drugs. Implementation strategies and outcomes should be documented to inform increased treatment coverage nationally, further advocating for the consideration of direct acting antivirals for inclusion in the primary care essential medicines list.

Tom Kehinde has posted an important perspective on local and community action in HIV control on the blog for the course Social and Behavioral Foundations of Primary Health Care. See the key issues from that posting below.

Nigeria grapples with one of the highest burdens of HIV/AIDS globally, with an estimated 1.9 million people living with the virus. Despite significant international assistance, the country heavily relies on external financing to combat the epidemic. This dependency on foreign aid is unsustainable in the long term and undermines Nigeria’s ability to address the epidemic effectively, perpetuating health disparities and social inequalities. Marginalized populations, such as women, youth, face heightened vulnerability to HIV infection due to limited access to prevention, treatment, and care services. To confront this pressing issue, empowering local HIV control organizations through increased domestic funding not only enhances their capacity to deliver targeted interventions but also fosters community ownership and sustainability.

(Photo source: The guardian)

Highlighting the position of stakeholders on this issue, firstly, WHO plays a pivotal role in providing technical guidance and support to countries like Nigeria in combating HIV/AIDS. Collaborating with WHO to develop evidence-based guidelines and technical assistance programs could bolster Nigeria’s efforts towards mobilizing domestic resources for HIV financing. National Agency for the Control of AIDS (NACA): the leading agency responsible for HIV/AIDS control in Nigeria, NACA advocates for increased domestic financing and empowerment of local HIV control organizations. Partnering with NACA to strengthen advocacy efforts and capacity-building initiatives could drive policy change. Despite the importance of mobilizing domestic resources for HIV financing, several challenges persist. These include inadequate funding allocations in national budgets, limited institutional capacity for effective resource mobilization and management. Developing a strategic plan such prioritizing advocacy for increased domestic funding for HIV/AIDS programs, enhance coordination among stakeholders, strengthen institutional capacity for resource mobilization and management, and promote community engagement and ownership of HIV/AIDS interventions. To conclude, mobilizing domestic resources for HIV financing is vital for Nigeria’s epidemic control. WHO must provide tailored guidelines, technical support, and advocate for local engagement. NACA should prioritize policy advocacy such as lobbying for increased budget allocations, strengthen collaboration as establishing joint task forces with other government agencies and NGOs, facilitating resource-sharing and coordinated efforts, and enhance community involvement. These concerted efforts will empower local organizations, bolster health systems, and mitigate the HIV burden, fostering sustainable development.

We occasionally share global health posts from the Blog, “Social, Cultural, and Behavioral Issues in PHC and Global Health“, a site that provides students from the Johns Hopkins Bloomberg School of Public Health a chance to learn about and create advocacy material. Below is a posting from May 9, 2021 by “laarnipatotoy“.

The Philippines has seen an increase in the incidence of HIV cases in recent years. According to UNAIDS report, there have been approximately 16,000 new cases of HIV in the county in the year 2019 alone.It is estimated that 83% of newly diagnosed cases of HIV are among men who have sex with men (MSM) and transgender women having sex with men (TGW), majority of which are between the ages of 15 to 24 years

old.In a 2015 survey conducted by the Philippines Department of Health illustrated that only 35% of MSM and TGW had proper knowledge on HIV.Many young Filipinos lack knowledge about HIV and other sexually transmitted diseases which is attributable to the absence of a comprehensive sexual education in schools and universities. Furthermore, only 40% of MSM admitted to using condoms according to the UNAIDS survey in 2018. The Philippine government have made efforts to address the rise of HIV cases in the country; however, policies’ restrictions on certain HIV programs create barriers to control and reverse the ascending trend of the epidemic.

The Philippines has seen an increase in the incidence of HIV cases in recent years. According to UNAIDS report, there have been approximately 16,000 new cases of HIV in the county in the year 2019 alone.It is estimated that 83% of newly diagnosed cases of HIV are among men who have sex with men (MSM) and transgender women having sex with men (TGW), majority of which are between the ages of 15 to 24 years old.In a 2015 survey conducted by the Philippines Department of Health illustrated that only 35% of MSM and TGW had proper knowledge on HIV.Many young Filipinos lack knowledge about HIV and other sexually transmitted diseases which is attributable to the absence of a comprehensive sexual education in schools and universities. Furthermore, only 40% of MSM admitted to using condoms according to the UNAIDS survey in 2018. The Philippine government have made efforts to address the rise of HIV cases in the country; however, policies’ restrictions on certain HIV programs create barriers to control and reverse the ascending trend of the epidemic.

The Catholic Church has been a significant influence in Philippine society and its political system since the Spanish colonization. Approximately 80 percent of Filipinos identify as Catholics, therefore laws and regulations are often aligned with the conservative teachings of the Roman Catholic Church. The Republic Act 10354: The Responsible Parenthood and Reproductive Health Act of 2012, also known as the Reproductive Health law, was passed by the government of the Philippines that secures the right of every national to have universal access to modern family planning, methods of contraception, sexual education, and reproductive health. Church leaders and other conservative officials opposed the RH law, proclaiming that it will only encourage acts of immorality. The Catholic Bishops Conference of the Philippines is in strong opposition against the distribution of contraceptives and integration of sexual education in schools. The institution advocates for abstinence as a solution to the growing HIV epidemic and advises government officials to rely on parents to educate their children regarding sex.

After only one year of the law’s passing, the Supreme Court announced its suspension following allegations from the CBCP that it is unconstitutional. In 2014, the Supreme Court lifted the suspension and deemed the RH law constitutional. Despite this major achievement, incidence of HIV cases continues to escalate and revisions to the current policies under RH law are necessary to control disease transmission. For instance, Section 7 of the RH Law declares that all citizens have access to family planning services with the exception of individuals under the age of 18, who are required to have consent from parents or legal guardians before access to contraceptives and family planning services are granted. This restriction inhibits sexually active teens and young adults to gain access to condoms which puts them at risk for contracting HIV and other sexually transmitted infections. In addition, Section 14 of the RH Law states that age and development-appropriate reproductive health education should be integrated in school curriculums only after consultations from school officials, interest groups and parent-teachers associations regarding course content. The section also declares the Department of Education to formulate a reproductive health curriculum to be applied in public schools and possibly adopted by private school institutions. This presents potential variations in the content of sex education and such inconsistencies can impact the quality of education the students receive.

As a healthcare professional, I strongly believe that a revision to the current Reproductive Health law in the Philippines, particularly in Section 7 and 14, is necessary to control the upsurge of HIV cases in the country. Mandatory enforcement of unbiased comprehensive sexual education in schools and revoking current age restrictions to condom access will eliminate barriers to condom use and safe sex practices. In addition, it will empower teens and young adults to make informed decisions regarding their reproductive health. The revision of the Reproductive Health law should be viewed in the broader context of disease control and prevention rather than a promotion of immorality and promiscuity. An effective, evidenced-based prevention strategy will facilitate the end of the HIV crisis in the country.

Today’s news featured a media briefing by the RBM Partnership and AMMREN on the challenges of protecting pregnant women from malaria. Additional news expands on these challenges. Research looks at how malaria parasites withstand the heat of a patient’s fever. Finally examples are presented of collaboration between international organizations and the private sector for malaria and disease control. Follow the links to gain more information.

Speed Up IPTp Scale-Up: a media briefing on maternal health

A panel discussion and media briefing on new approaches and lessons learned formed part of an online global call to end malaria in pregnancy with intermittent preventive treatment. The briefing on Tuesday, 6 October 2020, was sponsored by the Roll Back Malaria Partnership and AMMREN. The RBM website features background on the call to action.

The panel discussion included Dr. Aminata Cisse ep. Traore, Sous Directrice de la Santé de la Reproduction/Direction Générale de la Santé et de l’Hygiène Publique, Ministére de la Santé et de l’Hygiène Publique, Mali; Dr. Anshu Banerjee, Director Department of Maternal, Newborn, Child, Adolescent Health & Ageing, World Health Organization (WHO), and Dr. Pedro Alonso, Director Global Malaria Programme, WHO. The discussion was moderated by Mildred Komey, Malaria in Pregnancy Focal Person, National Malaria Control Program, Ghans Health Service.

The discussion covered the importance of launching this call now, what we’ve learned over the last few years, and examples of innovative strategies from Mali. There was a Q&A session with journalists after the presentations.

The presentation by Dr Alonso showed the progress in achieving IPTp coverage goals. He also pointed out the social and economic factors that affect access and equity to intermittent preventive treatment of malaria in pregnancy and protection of maternal health (see slides).

Experts say Africa must scale-up malaria protection for pregnant women

In support of the RBM/AMMREN briefing described above, Sola Ogundipe reports that amidst the COVID-19 pandemic in sub-Saharan Africa, malaria – one of the world’s oldest diseases – is impacting disproportionately on pregnant women and children aged under five.

For a pregnant woman, her fetus, and the newborn child malaria infection carries substantial risks. Calling for a speedy scale-up to boost protection against malaria for pregnant women in Africa, the Roll Back Malaria, RBM Partnership to End Malaria Working Group is issuing an urgent appeal to leaders and health policymakers to increase access to Intermittent Preventive Treatment during pregnancy, IPTp, among eligible pregnant women in sub-Saharan Africa.

Along with stakeholders, the RBM Partnership is pushing for scale-up coverage of three doses of IPTp to reach all eligible women in sub-Saharan Africa by 2025. In 2019, according to the RBM Partnership, an estimated 11 million pregnant women in sub-Saharan Africa, or 29 percent of all pregnancies were infected with malaria.

How malaria parasites withstand a fever’s heat

The parasites that cause 200 million cases of malaria each year can withstand feverish temperatures that make their human hosts miserable. Now, a team is beginning to understand how they do it. The researchers have identified a lipid-protein combo that springs into action to gird the parasite’s innards against heat shock.

Understanding how malaria protects its cells against heat and other onslaughts could lead to new ways to fight tough-to-kill strains, researchers say. Findings could lead to ways to maximize our existing antimalarial arsenal.

Global Fund and Chevron – United Against HIV, TB and Malaria

The Global Fund and Chevron Corporation have celebrated a 12-year partnership that served as an example of the private sector’s contribution to the fight against infectious diseases and to building resilient health systems. Chevron, a Global Fund partner since January 2008, has supported Global Fund programs against HIX4 tuberculosis and malaria for a total investment of US$60 million in Angola, Indonesia, Nigeria, the Philippines, South Africa, Thailand and Vietnam.

Chevron’s partnership has contributed to helping more than a million people living with HIV access lifesaving antiretroviral therapy; supported efforts to distribute over one million long-lasting insecticide-treated mosquito nets to families to prevent malaria; helped detect thousands of TB cases; promoted education programs for the young, and helped build stronger health systems.

In Nigeria, Chevron’s $5 million investment from October 2017 to December 201 9 supported the national HIV and TB programs, reaching key and vulnerable populations, as well as interventions aimed at strengthening the health system. Sustainable and resilient systems for health are indispensable in the fight against the epidemics of HIV TB and malaria, as well as the first line of defense against new diseases like COVID-19. “With rising cases of COVID-1 9, the stakes are very high. Deaths from HIV, TB and malaria are likely to increase. Investments by partners like Chevron are fundamental.

Today’s stories cover three continents including Surveillance for imported malaria in Sri Lanka, community perceptions in Colombia and Annual Fluctuations in Malaria Transmission Intensity in 5 sub-Saharan countries. In addition there is an overview of microscopy standards and an Integrated Macroeconomic Epidemiological Demographic Model to aid in planning malaria elimination. We also see how COVID-19 is disturbing Seasonal Malaria Chemoprevention activities in Burkina Faso. Read more by following the links in the sections below.

Will More of the Same Achieve Malaria Elimination?

… Results from an Integrated Macroeconomic Epidemiological Demographic Model. Historic levels of funding have reduced the global burden of malaria in recent years. Questions remain, however, as to whether scaling up interventions, in parallel with economic growth, has made malaria elimination more likely today than previously. The consequences of “trying but failing” to eliminate malaria are also uncertain. Reduced malaria exposure decreases the acquisition of semi-immunity during childhood, a necessary phase of the immunological transition that occurs on the pathway to malaria elimination. During this transitional period, the risk of malaria resurgence increases as proportionately more individuals across all age-groups are less able to manage infections by immune response alone. We developed a robust model that integrates the effects of malaria transmission, demography, and macroeconomics in the context of Plasmodium falciparum malaria within a hyperendemic environment.

The authors analyzed the potential for existing interventions, alongside economic development, to achieve malaria elimination. Simulation results indicate that a 2% increase in future economic growth will increase the US$5.1 billion cumulative economic burden of malaria in Ghana to US$7.2 billion, although increasing regional insecticide-treated net coverage rates by 25% will lower malaria reproduction numbers by just 9%, reduce population-wide morbidity by ?0.1%, and reduce prevalence from 54% to 46% by 2034. As scaling up current malaria control tools, combined with economic growth, will be insufficient to interrupt malaria transmission in Ghana, high levels of malaria control should be maintained and investment in research and development should be increased to maintain the gains of the past decade and to minimize the risk of resurgence, as transmission drops. © The American Society of Tropical Medicine and Hygiene [open-access]

Microscopy standards to harmonise methods for malaria clinical research studies

Research Malaria Microscopy Standards (ReMMS) applicable to malaria clinical research studies have been published in Malaria Journal. The paper describes the rationale for proposed standards to prepare, stain and examine blood films for malaria parasites. The standards complement the methods manual(link is external) previously published by the World Health Organization and UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR). The standards aim to promote consistency and comparability of data from microscopy performed for malaria research and hence to strengthen evidence for improvements in malaria prevention, diagnostics and treatment.

Microscopy is important in both malaria diagnosis and research. It is used to differentiate between Plasmodium species and stages and to estimate parasite density in the blood – an important determinant of the severity of disease. It is also used to monitor the effectiveness of drugs based on the rate at which parasites recrudesce or are cleared from the blood.

While rapid diagnostic tests have replaced microscopy in some contexts, microscopy remains an essential tool to support clinical diagnosis and research. The standardisation of methods allows direct comparisons from studies conducted across different points in time and location. This facilitates individual participant data meta-analyses, recognised as the gold standard approach to generate evidence for improvements in interventions and hence patient outcomes.

Estimating Annual Fluctuations in Malaria Transmission Intensity and in the Use of Malaria Control Interventions in Five Sub-Saharan African Countries

RTS,S/AS01E malaria vaccine safety, effectiveness, and impact will be assessed in pre- and post-vaccine introduction studies, comparing the occurrence of malaria cases and adverse events in vaccinated versus unvaccinated children. Because those comparisons may be confounded by potential year-to-year fluctuations in malaria transmission intensity and malaria control intervention usage, the latter should be carefully monitored to adequately adjust the analyses. This observational cross-sectional study is assessing Plasmodium falciparum parasite prevalence (PfPR) and malaria control intervention usage over nine annual surveys performed at peak parasite transmission. Plasmodium falciparum parasite prevalence was measured by microscopy and nucleic acid amplification test (quantitative PCR) in parallel in all participants, and defined as the proportion of infected participants among participants tested. Results of surveys 1 (S1) and 2 (S2), conducted in five sub-Saharan African countries, including some participating in the Malaria Vaccine Implementation Programme (MVIP), are reported herein; 4,208 and 4,199 children were, respectively, included in the analyses.

Plasmodium falciparum parasite prevalence estimated using microscopy varied between study sites in both surveys, with the lowest prevalence in Senegalese sites and the highest in Burkina Faso. In sites located in the MVIP areas (Kintampo and Kombewa), PfPR in children aged 6 months to 4 years ranged from 24.8% to 27.3%, depending on the study site and the survey. Overall, 89.5% and 86.4% of children used a bednet in S1 and S2, of whom 68.7% and 77.9% used impregnated bednets. No major difference was observed between the two surveys in terms of PfPR or use of malaria control interventions. © The American Society of Tropical Medicine and Hygiene [open-access]

Community perception of malaria in a vulnerable municipality in the Colombian Pacific

Malaria primarily affects populations living in poor socioeconomic conditions, with limited access to basic services, deteriorating environmental conditions, and barriers to accessing health services. Control programmes are designed without participation from the communities involved, ignoring local knowledge and sociopolitical and cultural dynamics surrounding their main health problems, which implies imposing decontextualized control measures that reduce coverage and the impact of interventions. The objective of this study was to determine the community perception of malaria in the municipality of Olaya Herrera in the Colombian Pacific.

A 41-question survey on knowledge, attitudes, and practices (KAP) related to malaria, the perception of actions by the Department of Health, and access to the health services network was conducted. In spite of the knowledge about malaria and the efforts of the Department of Health to prevent it, the community actions do not seem to be consistent with this knowledge, as the number of cases of malaria is still high in the area.

Use of a Plasmodium vivax genetic barcode for genomic surveillance and parasite tracking in Sri Lanka

Sri Lanka was certified as a malaria-free nation in 2016; however, imported malaria cases continue to be reported. Evidence-based information on the genetic structure/diversity of the parasite populations is useful to understand the population history, assess the trends in transmission patterns, as well as to predict threatening phenotypes that may be introduced and spread in parasite populations disrupting elimination programmes. This study used a previously developed Plasmodium vivax single nucleotide polymorphism (SNP) barcode to evaluate the population dynamics of P. vivax parasite isolates from Sri Lanka and to assess the ability of the SNP barcode for tracking the parasites to its origin.

A total of 51 P. vivax samples collected during 2005–2011, mainly from three provinces of the country, were genotyped for 40 previously identified P. vivax SNPs using a high-resolution melting (HRM), single-nucleotide barcode method. The proportion of multi-clone infections was significantly higher in isolates collected during an infection outbreak in year 2007. Plasmodium vivax parasite isolates collected during a disease outbreak in year 2007 were more genetically diverse compared to those collected from other years. In-silico analysis using the 40 SNP barcode is a useful tool to track the origin of an isolate of uncertain origin, especially to differentiate indigenous from imported cases. However, an extended barcode with more SNPs may be needed to distinguish highly clonal populations within the country.

Coronavirus rumours and regulations mar Burkina Faso’s malaria fight

By Sam Mednick, Thomson Reuters Foundation: MOAGA, Burkina Faso – Health worker Estelle Sanon would hold the 18-month-old and administer the SMC dose herself, but because of coronavirus she has to keep a distance from her patients. “If I am standing and watching the mother do it, it’s as if I’m not doing my work,” said Sanon, a community health volunteer assisting in a seasonal campaign to protect children in the West African country from the deadly mosquito-borne disease.

Burkina Faso is one of the 10 worst malaria-affected nations in the world, accounting for 3% of the estimated 405,000 malaria deaths globally in 2018, according to the World Health Organization (WHO). More than two-thirds of victims are children under five. Now there are fears malaria cases could rise in Burkina Faso as restrictions due to coronavirus slow down a mass treatment campaign and rumours over the virus causing parents to hide their children, according to health workers and aid officials.

“COVID-19 has the potential to worsen Burkina Faso’s malaria burden,” said Donald Brooks, head of the U.S. aid group Initiative: Eau, who has worked on several public health campaigns in the country.  “If preventative campaigns can’t be thoroughly carried out and if people are too scared to come to health centres … it could certainly increase the number of severe cases and the risk of poor outcomes.”

During peak malaria season, from July to November, community health workers deploy across Burkina Faso to treat children with seasonal malaria chemoprevention (SMC). This is the second year the campaign will cover the whole country with more than 50,000 volunteers going door-to-door, said Gauthier Tougri, coordinator for the country’s anti-malaria programme. Logistics were already challenging. Violence linked to jihadists and local militias has forced more than one million people to flee their homes, shuttered health clinics and made large swathes of land inaccessible. Now the coronavirus has made the task even harder, health workers said.

People in Cape Verde evolved better malaria resistance in 550 years

Yes, we are still evolving. And one of the strongest examples of recent evolution in people has been found on the Cape Verde islands in the Atlantic, where a gene variant conferring a form of malaria resistance has become more common.

Portuguese voyagers settled the uninhabited islands in 1462, bringing slaves from Africa with them. Most of the archipelago’s half a million inhabitants are descended from these peoples. Most people of West African origin have a variant in a gene called DARC that protects.

Deadly malaria and cholera outbreaks grow amongst refugees as COVID pandemic strains health systems.

Apart from the strain on health facilities during the pandemic, in some countries such as Somalia, Kenya and Sierra Leone, we are seeing that a fear of exposure to COVID-19 has prevented parents from taking their children to hospital, delaying diagnosis and treatment of malaria and increasing preventable deaths. COVID restrictions in some countries have also meant pregnant women have missed antimalarial drugs. Untreated malaria in pregnant women can increase the risk of anaemia, premature births, low birth weight and infant death. According to the World Health Organization (WHO), 80% of programs designed to fight HIV, tuberculosis and malaria have been disrupted due to the pandemic and 46% of 68 countries report experiencing disruptions in the treatment and diagnosis of malaria.

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 western 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.

World 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.”

Drugs 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 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.

1. 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).

One-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).

World 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.

Both 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.

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.”

Efforts 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.