Increased prevalence of malaria in HIV‐infected pregnant women and its implications for malaria control

Abstract

Summaryobjectives To examine in pregnant women the relationship between HIV infection and malaria prevalence and to determine, in relation to HIV infection, the effectiveness of sulphadoxine-pyrimethamine in clearing P. falciparum infection.method Descriptive cross-sectional analysis of P. falciparum prevalence in pregnant women at first antenatal visit and of women at delivery who had received two sulphadoxine-pyrimethamine treatments for malaria. HIV status was assessed in 621 women who attended for antenatal care and for delivery at two rural hospitals in southern Malawi in 1993-94. Information was collected on maternal age, parity and gestational age. Prevalence of P. falciparum was measured at first antenatal visit and delivery. Women were given two routine treatment doses of sulphadoxine-pyrimethamine (SP), at first antenatal visit and between 28 and 34 weeks gestation, conforming to Malawi government policy on antimalarial control during pregnancy.results Prevalence of HIV infection was 25.6% and all infections were HIV type-1. In primigravidae malaria prevalence at recruitment was 56.3% in HIV-infected and 36.5% in HIV-uninfected women (P ϭ 0.04). The corresponding figures for multigravidae were 23.8% and 11.0%, respectively (P Ͻ 0.01). HIVinfected primigravidae had increased malaria prevalence at all gestational ages. Peak parasite prevalence occurred earlier in gestation in HIV-infected primigravidae (16-19 weeks if HIV-infected; 20-23 weeks if HIV-uninfected). The relative risk for parasitaemia in HIV-infected compared to HIV-uninfected women was significantly increased in three of five parity groups, including the two highest ones (parity Ͼ3), indicating parity-specific immunity to malaria was impaired. Malaria prevalence at delivery remained high in HIV-infected women despite prior routine treatment with sulphadoxine-pyrimethamine in pregnancy. There was no significant difference in parasite prevalence at delivery between women who did or did not use sulphadoxine-pyrimethamine.conclusions HIV infection is associated with a significant increase in malaria prevalence in pregnant women of all parities with the effect apparent from early in gestation. Two treatment doses of sulphadoxine-pyrimethamine were inadequate to clear parasitaemia in many women by the time of delivery and this occurred independently of HIV status and despite high sensitivity to SP in this area. There is a need to undertake longitudinal studies to determine the incidence of P. falciparum infection in HIV-infected and uninfected pregnant women and to reassess the frequency and timing of sulphadoxine-pyrimethamine treatment doses in these women. Late pregnancy re-infections with P. falciparum probably explain the high parasite prevalence at delivery following sulphadoxinepyrimethamine treatment at 28-34 weeks gestation. keywords pregnancy, malaria, HIV, antimalarial control, sulphadoxine-pyrimethamine correspondence Professor B.J. Brabin,

Adverse birth outcomes in United Republic of Tanzania - impact and prevention of maternal risk factors

“…[37][38][39] Paritys specific immunity appears to be reduced in HIVspositive women; women of all parities have a higher relative risk for malaria if they are HIVspositive. 27,37,39,40 This in turn may lead to an even higher rate of adverse pregnancy outcomes, als s though we did not observe this, with the exception of a univariate effect of HIV on stillbirth. Any effect on pregnancy outcome may be partially mediated through the effect of HIV infection on malaria and/or anaemia.…”

“…38 Similar findings have been reported from Malawi. 40 In developing countries, maternal anaemia is usually the result of iron deficiency and/or malaria. Hookworm infection and poor diet are believed to be important causes of iron deficiency.…”

Adverse birth outcomes in a malarious area

“…8) for this cohort of mothers [9]. The lack of an association in the present study may relate to the small sample size of women tested for HIV, or confounding as maternal HIV infection has been significantly associated with increased malaria prevalence during pregnancy [27,28].…”

Breast and complementary feeding practices in relation to morbidity and growth in Malawian infants

“…It was also associated with a lower incidence of malaria and eye infection, and improved growth in these infants. In this area, maternal prevalence of HIV/AIDS is high at 25.6% (Verhoeff et al, 1999). The cumulative infant HIV infection rate in breastfeeding infants has been reported to be as high as 7% per annum in Malawi (Miotti et al, 1999).…”