Text smaller | Text larger | Text Only

HIV/AIDS and Malaria

Overview:

Malaria and HIV are two of the most devastating global health problems. Together they cause more than 4 million deaths a year. Both are diseases of poverty, and both are causes of poverty. There is considerable geographic overlap between their distributions: 90% of deaths attributable to malaria occur in children in sub-Saharan Africa, while an estimated 29 million people are living with HIV/AIDS in sub-Saharan Africa, many of whom are under five-year-olds. The resulting co-infection and interaction between the two diseases have major public health implications.

HIV infection leads to lower immune status, including a low CD4 T cell count and this leads to increased risk of malaria infection, increased recrudescence of malaria and anti-malarial treatment failure. In turn, clinic malaria episodes cause increased viral load of HIV. In settings with unstable malaria, HIV-infected adults are at increased risk of complicated and severe malaria and death.

Pregnant women are particularly vulnerable: co-infection leads to greater levels of anaemia, and placental malaria, and while it may not increase mother-to-child transmission with HIV, the child is often born with low birth weight, and increased child mortality rates have been reported. In women who are not HIV positive, primigravidae are more likely to develop severe or complicated malaria. In HIV positive pregnant women, however, this shifts so that all women are at risk.

HIV-infected persons are at increased risk of clinical malaria; the risk is greatest when immune suppression is advanced. Adults with advanced HIV infection may be at risk of failure of malaria treatment, especially with sulfa-based therapies. Malaria is associated with increases in HIV viral load that, while modest, may affect HIV progression or the risk of HIV transmission. Cotrimoxazole prophylaxis significantly reduces the risk of malaria in people with HIV; the risk can be further reduced with antiretroviral treatment and the use of insecticide treated mosquito nets. Increased numbers of doses of intermittent preventive treatment during pregnancy can reduce the risk of placental malaria in women with HIV. Treatment of the two infections can also have complications: sulfadoxine-pyrimethamine used in the treatment of malaria and cotrimoxazole for opportunistic bacterial infections in HIV positive patients are a similar class of drugs, and may result in overdosing, or may lead to the development of resistance. Protease inhibitors for HIV infection are contraindicated with the drugs lumefantrine and halofantrine for malaria treatment.

Key Points:

  • HIV-infected people must be considered particularly vulnerable to malaria, with increased parasite load and clinical symptoms.
  • Malaria infection increase HIV viral load.
  • Pregnant women and their newborns are at high risk.
  • 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.
  • Drug management for either disease must take into account medications for the other.
  • Cotrimoxazole prophylaxis given to HIV positive people reduces the number of clinical attacks of malaria in co-infection.

References:

  1. Shah, S.N., Smith, E.E., Obonyo, C.O., Kain, K.C., Bloland, P.B., Slutsker, L. & Hamel, M.J. (2006) HIV Immunosuppression and antimalarial efficacy: sulfadoxine-pyrimethamine for the treatment of uncomplicated malaria in HIV-infected adults in Siaya, Kenya. Journal of Infectious Diseases 194(11): 1519-28.
  2. Van Geertruyden, J.P., Mulenga, M., Mwananvanda, L., Chalwe, V., Moerman, F., Chilengi, R., Kasongo, W., Van Overmeir, C., Dujardin, J.C., Colebunders, R., Kestens, L & D'Alessandro, U. (2006) HIV-1 immune suppression and antimalarial treatment outcome in Zambian adults with uncomplicated malaria. Journal of Infectious Diseases 194(7): 917-925.
  3. Patnaik, P., Jere, C.S., Miller, W.C., Hoffman, I.F., Wirima, J., Pendame, R., Meshnick, S.R., Taylor, T.E., Molyneux, M.E. & Kublin, J.G. (2005) Effects of HIV-1 serostatus, HIV-1 RNA concentration, and CD4 cell count on the incidence of malaria infection in a cohort of adults in rural Malawi. Journal of Infectious Diseases. 192(6): 984-91.
  4. Van Geertruyden, J.P., Mulenga, M., Kasongo, W., Polman, K., Colebunders, R., Kestens, L., D'Alessandro, U. (2006) CD4 T-cell count and HIV-1 infection in adults with uncomplicated malaria. Journal of Acquired Immune Deficiency Syndrome 43(3): 363-7.
  5. Brabin, L. & Brabin, B.J. (2005) HIV, malaria and beyond: reducing the disease burden of female adolescents. Malaria Journal 4:2
  6. Korenromp, E.L., Williams, B.G., de Vlas, S.J. & Gouws, E. (2005) Malaria Attributable to the HIV-1 Epidemic, Sub-Saharan Africa Emerging Infectious Diseases 11(9): 1410-1419.
  8. Technical Consultation on Malaria and HIV Interactions and Public Health Policy Implications (2004 : Geneva, Switzerland) Malaria and HIV interactions and their implications for public health policy.
  9. Hecht, R., Alban, A., Taylor, K., Post, S., Andersen, N.B. & Schwarz, R. (2006). Putting it together: AIDS and the Millennium Development Goals, PLoS Med. 3(11): e455.