Preventing malaria in HIV-infected pregnant women.

Efforts to curb or eliminate malaria incidence in areas with a high prevalence of human immunodeficiency virus (HIV) face many challenges, chief among which are inconsistent access to proven interventions and limited resources of prevention and control programs. These challenges are compounded by the fact that HIV and malaria interact synergistically, with HIV increasing the risk and severity of clinical malaria and malaria increasing the viral load and hence transmission of HIV [1]. Coinfection with malaria and HIV is of special concern for pregnant women. In sub-Saharan Africa, where more than three-quarters of the world’s HIV-infected women reside, an estimated 30 million women are at risk of acquiring Plasmodium falciparum malaria every year [2]. Coinfection during pregnancy imperils both maternal and newborn health outcomes. HIV-infected pregnant women are at increased risk of parasitemia and clinical malaria throughout their pregnancy, and this increased risk is particularly apparent in multiparous women who in the setting of HIV infection do not develop the parity-dependent antimalarial immunity typically observed in areas of high malaria transmission. Coinfected women are also at increased risk of developing severe anemia and placental malaria. Placental malaria and HIV coinfection has been shown to predispose to higher rates of neonatal mortality, preterm delivery, low birth weight, and, in some settings, increased risk of mother-to-child transmission of HIV [3, 4], highlighting the critical need for evaluation and delivery of effective prevention strategies. Prevention of malaria in HIV-infected pregnant women in areas of stable malaria transmission currently relies upon a combination of insecticide-treated bednet (ITN) use, intermittent preventive therapy with sulfadoxine-pyrimethamine (IPT-SP), and prompt management of clinical malaria episodes and anemia. ITNs and IPT-SP have been shown to be highly efficacious in preventing malaria among pregnant women, but coverage levels for both interventions have been inadequate, despite high attendance at antenatal care centers [5]. Alarmingly, IPT coverage rates appear to be lowest in regions of high-intensity malaria transmission. The World Health Organization (WHO) recently released new guidelines simplifying and reinforcing their recommendation to give IPT-SP to all pregnant women not on co-trimoxazole (CTX) prophylaxis in an effort to improve coverage [6]. WHO currently recommends a daily double-strength tablet of CTX (800 mg sulfamethoxazole + 160 mg trimethoprim) for all HIVinfected pregnant women who meet adult eligibility criteria to prevent opportunistic infections [7, 8]. In previous studies, CTX was found to be efficacious in preventing clinical malaria [9, 10], leading to the hypothesis that CTX could serve as an alternative to IPT-SP. However, efficacy relative to standard IPT, toxicity, and birth outcomes associated with CTX chemoprophylaxis for P. falciparum have not been adequately assessed in HIVinfected pregnant women [11]. In this issue of Clinical Infectious Diseases, Klement and colleagues report the results of a randomized noninferiority trial conducted in Togo comparing the effect of daily CTX vs IPT-SP on the risk of maternal malaria, parasitemia, placental malaria, anemia, and birth outcomes among HIV-infected pregnant women [12]. In the study, 126 women were randomly assigned to receive daily CTX and 124 to receive IPT-SP in an area of high P. falciparum transmission. Over the course of the study, there was no significant difference in malaria incidence rate during pregnancy between the 2 groups; however, CTX prophylaxis failed to reach Received 2 December 2013; accepted 3 December 2013; electronically published 12 December 2013. Correspondence: Philip L. Bulterys, BS, 254 Biomedical Science Research Building, 615 Charles E. Young Dr. South, Los Angeles, CA 90095 ([email protected]). Clinical Infectious Diseases 2014;58(5):660–2 © The Author 2013. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals. [email protected]. DOI: 10.1093/cid/cit805