UNICEF Malaria Technical Note # 6 February 2003

Malaria and HIV/AIDS

Background: As HI s!rea"s# it interacts $ith other in%ectious "iseases# %acilitate" by the increase in nu&bers o% i&&unosu!!resse" in"i'i"uals an" because its o$n clinical course can be altere" by other in%ections( In%ectious "iseases o%ten )syner*i+e,# or ne*ati'ely a%%ect each other# an" this is &ost noticeable $ith HI an" tuberculosis -T./( In areas o% hi*h HI !re'alence# the inci"ence o% T. in%ection is increase"# $ith a resultant increase in &ortality( In a""ition# susce!tibility to HI can be increase" by other in%ections# notably se0ually trans&itte" in%ections -1TIs/# lea"in* to hi*h rates o% HI trans&ission in co&&unities $ith hi*h !re'alence o% 1TIs( In A%rica# the HI !an"e&ic has been su!eri&!ose" on the lon*stan"in* &alaria !an"e&ic# $here P. falciparum &alaria is consistently one o% the &a2or causes o% in%ant an" chil" &ortality( The hi*h !re'alence o% both HI an" &alaria in%ection in A%rica &eans that e'en s&all interactions bet$een the t$o coul" ha'e substantial e%%ects on !o!ulations( 3ith the ince!tion o% the 4oll .ac5 Malaria !artnershi! in 1667# there $as reco*nition that !re'ious *ra"ual "eclines in &alaria &ortality ha" been re'erse" "urin* the 1660,s# an" that interactions bet$een &alaria an" HI coul" be one contributor( Early research "i" not in"icate any "irect# biolo*ical association bet$een HI an" &alaria# althou*h it $as note" that &alaria8associate" anae&ia treate" $ith unscreene" bloo" trans%usions contribute" to HI trans&ission( In &ore recent years# three 5ey issues ha'e %ocusse" &uch o% the research e%%ort9 1( :oes HI ;AI:1 increase susce!tibility to &alaria in%ection or increase se'erity o% acute &alarial e!iso"es< 2( :oes &alaria in%ection accelerate !ro*ression o% HI ;AI:1< 3( 3hat is the i&!act o% &alaria an" HI co8in%ection "urin* !re*nancy< Current Status: Effect of HIV on malaria: HI in%ection increases the inci"ence an" se'erity o% clinical &alaria( In non8!re*nant a"ults# HI in%ection has been %oun" to rou*hly "ouble the ris5 o% &alaria !arasite&ia an" clinical &alaria( In east an" southern A%rica# $here HI !re'alence is near 30=# it is esti&ate" that about one8>uarter to one8thir" o% clinical &alaria in a"ults -inclu"in* "urin* !re*nancy/ can be accounte" %or by HI ( ?ittle research has been carrie" out in chil"ren# althou*h anae&ia %ro& &ulti!le causes is co&&on an" associate" $ith increase" &ortality in HI 8in%ecte" chil"ren( Effect of malaria on HIV: Althou*h the e%%ect o% &alaria on HI has not been so $ell "ocu&ente"# so&e recent research is no$ a""in* to the *ro$in* bo"y o% e'i"ence( Acute &alaria in%ection increases 'iral loa"# an" one stu"y %oun" that this increase" 'iral loa" $as re'erse" by e%%ecti'e &alaria treat&ent( This &alaria8associate" increase in 'iral loa" coul" lea" to increase" trans&ission o% HI an" &ore ra!i" "isease !ro*ression# $ith substantial !ublic health i&!lications(

UNICEF Malaria Technical Note # 6 February 2003

@ne recent stu"y %oun" that "aily cotri&o0a+ole !ro!hyla0is a&on* HI 8in%ecte" a"ults re"uce" &alaria inci"ence by 70= in U*an"a( Althou*h this e%%ect $oul" be e0!ecte" to 'ary# "e!en"in* on e!i"e&iolo*ical settin* an" !atterns o% "ru* resistance# it &ay be rele'ant %or both !re*nant $o&en an" a"ults &ore *enerally( HIV and malaria co-infection during pregnancy: Malaria in%ection is &ore %re>uent an" &ore se'ere in HI 8!ositi'e !re*nant $o&en in &alaria8en"e&ic settin*s( Multi*ra'i"ae $ith HI in%ection are si&ilar to !ri&i*ra'i"ae $ithout HI in%ection in ter&s o% susce!tibility to# an" ne*ati'e conse>uences o%# &alaria in%ection( There%ore# in the !resence o% HI in%ection# the ris5 associate" $ith !lacental &alaria a!!ears to be in"e!en"ent o% the nu&ber o% !re*nancies( Are*nant $o&en in%ecte" $ith both &alaria an" HI are at hi*her ris5 o% "e'elo!in* anae&ia# "eli'erin* a lo$ birth$ei*ht in%ant# an" "eli'erin* !re&aturely( Hi*her 'iral loa" increases the li5elihoo" o% &aternal8to8chil" trans&ission -MTCT/ o% HI ( Malaria in%ection "urin* !re*nancy increases ris5s o% MTCT in the intrauterine an" intra!artu& !erio" as $ell as "urin* the breast%ee"in* !erio"# !resu&ably by increasin* HI 'iral loa"( More $or5 is nee"e" to e0a&ine the e%%ects an" !ublic health i&!lications o% &alaria an" HI ( Technical Issues: I% the transient ele'ation in 'iral loa" associate" $ith &alaria in%ection can be re'erse" $ith e%%ecti'e &alaria treat&ent -as sho$n by !ros!ecti'e stu"ies/# &alaria !re'ention an" control &ay !ro'e to be bene%icial in re"ucin* HI trans&ission an" slo$in* !ro*ression to AI:1( ?ar*e8scale use o% tri&etho!ri&8sul%a&etho0a+ole -cotri&o0a+ole/ %or !ro!hyla0is o% o!!ortunistic in%ections in HI 8!ositi'e !atients# althou*h o% !ossible bene%it in re"ucin* the inci"ence o% &alaria# &ay also increase "ru* !ressure %or other anti%olate co&binations( This &ay !otentially accelerate resistance to sul%a"o0ine8 !yri&etha&ine -1A/# $hich is bein* increasin*ly use" %or the treat&ent o% acute unco&!licate" &alaria in A%rica an" antenatal IAT !ro*ra&&es( Con'ersely# e0!an"in* use o% 1A in A%rica &i*ht %urther the "e'elo!&ent o% resistance to cotri&o0a+ole by other !atho*ens# such as Streptococcus pneumoniae( The e%%ecti'eness o% both o% these "ru*s nee"s to be care%ully &onitore" in country !ro*ra&&es( It is esti&ate" that B=810= o% ne$ HI in%ections are cause" by unsa%e bloo" !ro"ucts( This has enor&ous i&!lications %or the &ana*e&ent o% se'ere anae&ia# inclu"in* that $hich occurs "urin* chil"hoo" as a result o% se'ere &alaria in%ection -see belo$/(

UNICE !s "ole: Fi*htin* HI ;AI:1 is one o% the %i'e or*ani+ational !riorities un"er the MT1A# an" UNICEF E1A4@ has i"enti%ie" HI ;AI:1 as the C!riority o% !rioritiesD %or the re*ion( As a result# countries are to re8orient their !ro*ra&&es to re%lect this !riority# creatin* o!!ortunities %or lin5a*e an" collaboration across 'arious !ro*ra&&e areas(

UNICEF Malaria Technical Note # 6 February 2003

The association bet$een HI an" &alaria hi*hli*hts the nee" %or !re'ention an" control o% both o% these *lobal !an"e&ics to be syner*istic( In other $or"s# !re'ention o% HI ;AI:1 shoul" be 'ie$e" as an i&!ortant co&!onent o% &alaria control in countries $ith hi*h rates o% HI sero!re'alence# an" &alaria !re'ention an" control shoul" be 'ie$e" as an i&!ortant ele&ent in the !re'ention an" control o% HI ;AI:1 in &alaria8 en"e&ic countries( This re>uires the %or&ation o% e%%ecti'e !artnershi!s an" i&!ro'e" collaboration bet$een the t$o !ro*ra&&e entities( For the co8in%ecte" !re*nant $o&an# e%%ecti'e "eli'ery o% inter'entions %or the !re'ention an" control o% both &alaria an" HI # inclu"in* AMTCT as a!!ro!riate# is 'ital( The i&!lications %or UNICEF country !ro*ra&&es re'ol'e aroun" t$o 5ey areas9 1( Manage#ent and Control o$ Anae#ia: This is !articularly i&!ortant %or t$o hi*h ris5 *rou!s# in%ants an" !re*nant $o&en( Anae&ia relate" "eaths can be re"uce" by an inte*rate" !ro*ra&&e $hich inclu"es &alaria !re'ention an" control# !articularly ITNs an" inter#ittent %re&enti&e treat#ent -IAT/ %or both !re*nant $o&en an" in%ants -see 3H@;UNICEF 2oint state&ent on IATI/( 4e"ucin* the inci"ence o% se'ere anae&ia throu*h &alaria control acti'ities# an" other !ublic health inter'entions# $oul" lessen the nee" %or the use o% !ossibly unsa%e bloo" !ro"ucts %or trans%usion( 2( I#%ro&ed Antenatal Care: Hi*h rates o% antenatal atten"ance by !re*nant $o&en in A%rica su**est that the e%%ects o% HI an" &alaria "urin* !re*nancy coul" be a!!roache" throu*h a C!ro*ra&&e !artnershi!D %or i&!ro'e" antenatal care -see 4e!ro"ucti'e Health Aac5a*e technical note/( Eoint !ro*ra&&in* to stren*then antenatal care# inclu"in* access to HI "ia*nosis an" antiretro'iral "ru*s %or 'MTCT# in a""ition to I'T# "istribution o% ITNs# an" i&!ro'e" &alaria case &ana*e&ent# coul" ha'e si*ni%icant i&!act an" lon*8ter& bene%its %or $o&en an" chil"ren( ?in5in* t$o hi*h !riority UNICEF !ro*ra&&es -AMTCT an" 4.M/# aroun" e%%orts to stren*then antenatal care# has the !otential to re"uce &aternal8to8chil" trans&ission o% HI an" i&!ro'e outco&es %or $o&en an" chil"ren( In both cases# it is i&!ortant to &onitor co'era*e o% inter'entions to control anae&ia an" i&!ro'e antenatal care# so that the i&!act o% UNICEF country !ro*ra&&es can be assesse"( "eadings: Corbett E? et al# AI:1 In A%rica III9 HI 81;AI:1 an" the control o% other in%ectious "iseases in A%rica( Lancet 2002F 3B69 21GG87G(