HIV and malaria

HIV and malaria

      HIV and Malaria in Sub Saharan Africa
• Both are epidemics in Sub Saharan Africa (SSA) that may interact with each other
• Number of people living with HIV: 22.4 million (WHO/UNAIDS, 2009)
o More than 60% of those infected with HIV globally
• 300-500 million clinical malaria disease episodes globally; SSA is home to:
o 60% of the cases of clinical malaria
o 75% of the deaths are in children <5years in SSA
o Over 90% (around 1 million) of the deaths caused by malaria

Overview of Malaria in Tanzania
• In Tanzania, 16-18 million cases each year (MOHSW, 2006)
• Malaria accounts for 100 000 deaths per year
o 70% of deaths occur in children <5 years
• Malaria accounts for severe morbidity in Tanzania:
o 30% of the national disease burden
o 43% of under 5 outpatient attendance
o 35-37% of under 5 hospital deaths
Relationship between HIV on Malaria

Effects of HIV on Malaria
• HIV affects the immune system which impairs the body’s ability to resist malaria
• T-cells are essential mediators of anti-malaria immunity
• HIV infection may cause:
o Increased susceptibility to malaria
o Increased severity of malaria
o Poor outcomes of treatment
• HIV adds to the burden of complications such as nutritional problems and anaemia (iron deficiency)
• HIV infection increases the incidence of malaria
• The risk of clinical malaria (fever and positive blood smears) is higher in HIV positive adults

Effects of Malaria on HIV
• The risk of malaria increases as CD4 count decreases

Malaria greatly increases HIV viral load
• Malaria may increase HIV disease progression through activation of T-lymphocytes, some of which may be infected with HIV
• HIV viral load increased during malaria episodes
• The viral load increases were highest in those who had fever, high number of parasites and those with high CD4
• Malaria control is important for delaying HIV progression
• Malaria prevention should be a priority
Patients presenting with clinical malaria may be HIV co-infected and therefore should be offered HIV testing
      HIV and Malaria Co-Infection during Pregnancy
• Malaria infection is more frequent and more severe in HIV-positive pregnant women
• Pregnant women infected with both malaria and HIV is at higher risk of:
o Developing anaemia
o Delivering a low birth weight infant
o Delivering prematurely
• Malaria infection during pregnancy increases risks of MTCT in the intrauterine and intrapartum period as well as during the breastfeeding period, possibly by increasing HIV viral load

Clinical Features of Uncomplicated Malaria in PLHIV
• PLHIV with malaria are more likely to be symptomatic and have higher number of
parasites in blood than HIV-negative patients
• Symptoms may be more severe and persistent
• Patients with malaria may present with the following:
o Fever
o Anaemia
o Headache
o Diarrhoea
o Joint aches
• The symptoms listed above may even be absent in patients with malaria

Forms of Complicated Malaria in HIV
• Severe malaria may manifest as cerebral malaria or severe anaemia
• Cerebral malaria frequently resembles other CNS complications of HIV

• Severe anaemia in HIV may be due to multiple causes including
o Malaria
o HIV itself
o Nutritional deficiency
o Side effects of drugs e.g. Zidovudine, Cotrimoxazole
• Patients with HIV who get malaria may also present with other forms of complicated malaria as in non-HIV patients e.g. pulmonary oedema, jaundice, hypoglycaemia, acidosis, organ failure (heart and renal)

Approach to Diagnosis of Malaria in PLHIV
• Many patients with HIV first present with intermittent fever which is frequently treated as malaria or typhoid
• History of repeated malaria treatment should trigger suspicion of HIV infection
• It is important to offer HIV testing to all patients presenting to hospital through PITC
• Similarly, patients with HIV and fever and other symptoms should be tested for malaria
• Detailed history taking is important to exclude other OIs
• General examination to exclude anaemia, jaundice and other HIV-related conditions
• Complete physical examination to exclude:
o Other OIs
o Complications such as anaemia
• Laboratory tests for diagnosis should include:
o Malaria smear
     A negative smear does not exclude malaria
• Other tests to exclude OIs can be done depending on the symptoms the patient presents with e.g. LP for unconscious or convulsing patient

Management of Malaria in PLHIV
• Malaria should be:
o Suspected in all PLHIV who present with fever and other symptoms
o Managed the same way as for non HIV-infected adults

• Treatment of uncomplicated malaria involves giving ALU (a fixed dose combination of Artemether and Lumefantrine) orally
• There are few potential interactions between anti-malarials and 1st line ARV regimens
o Nevirapine or Efavirenz may lower levels of Artemether
o In that situation you can shift to second line treatment of malaria as per guideline
o For patients on 2nd line regimens, artemether and lumefantrine may increase toxicity of protease inhibitors
• Treatment of complicated malaria requires administration of Quinine but patients need to be referred to higher facilities for farther management
o It may be given orally, intramuscularly or intravenously
o There are no potential interactions between quinine and ARVs

Prevention of Malaria in PLHIV
• Insecticide Treated Nets (ITNs) reduce mosquito bites and are recommended for PLHIV
• Cotrimoxazole preventive therapy (CPT) has been demonstrated to prevent malaria in patients on prophylaxis
• HIV-positive pregnant women should receive Intermittent preventive treatment (IPT) OR daily cotrimoxazole preventive therapy

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