Malaria

A meta-analysis of studies assessing the impact of use of insecticide treated bednets (ITNs) on pregnant women found that use of ITNs compared to no use reduced placental parasitemia (malaria parasites in the placenta) by 23% and miscarriages and stillbirths by 33%. Three cluster-randomized and two individually randomized trials, four from Africa with 6,418 pregnant women and one from Thailand with 223 pregnant women, were included in the meta-analysis. Some women in the cluster-randomized trials became pregnant after ITNs were distributed and were therefore protected throughout pregnancy, when the risk of malaria parasitemia is greatest. ITNs used by the whole community results in area-wide reductions in malaria transmission.

A prospective cohort study in Uganda funded by PEPFAR found that co- trimoxazole prophylaxis, antiretroviral therapy and insecticide treated bednets substantially reduced the frequency of malaria in adults with HIV. Of 466 people living with HIV aged 18 and over, 75% were women, of whom 56 died and 11 were lost to follow-up and none received an intervention. Of the 399 remaining who started co-trimoxazole, 138 survived and were clinically eligible for antiretroviral therapy and received both co-trimoxazole and antiretroviral therapy. In addition to these 138 who received both co- trimoxazole and antiretroviral therapy, an additional 897 additional people also received both co-trimoxazole and antiretroviral therapy. Of these 1,035 people who received co-trimoxazole and antiretroviral therapy, 45 died and five moved or were lost to follow-up. The remaining 985 people also received insecticide treated bednets, including four people who started co-trimoxazole, antiretroviral therapy and received ITNs simultaneously. CD4 counts were taken when first enrolled and at regular intervals. Antiretroviral therapy was delivered to homes in prepackaged pillboxes and pills were counted at each visit. According to pill counts, 98% took at least 95% of the prescribed antiretroviral therapy. Two insecticide treated bednets were given to all households with instructions for use. Median follow up before co-trimoxazole was 154 days; during co-trimoxazole and antiretroviral therapy 126 days; and during co-trimoxazole, antiretroviral therapy and ITNs, 560 days. 120,750 home visits were done. Compared with no intervention, co-trimoxazole prophylaxis was associated with a 76% lower malaria rate (9.0 versus 50.8 episodes per 100 person-years); antiretroviral therapy and co-trimoxazole with a 92% lower malaria rate; and co-trimoxazole, antiretroviral therapy and ITNs with a 95% lower malaria rate (50.8 episodes per 100 person years to 2.1 episodes per 100 person years among people living with HIV) than during the time with no intervention of co-trimoxazole.

Starting in 2006, the government of Rwanda scaled up preventive and curative malaria interventions, increasing access to Artemisinin Combination Therapies (ACT) and delivering 1.6 million ITNs in one week with an additional 1.6 million ITNs distributed by April 2009 through ANC and community health workers, reducing deaths from malaria by 60%. Because everyone in the household received an ITN, pregnant women were ensured access to ITNs. Approximately 60% of pregnant women in 2007 slept under ITNs. Nine of ten private pharmacies now carry ACT. Between 2001 and 2005 only a few hundred thousand ITNs were distributed with negligible impact.

A study that analyzed medical records for three years, from 2005 to 2007, in Uganda, found that HIV-positive patients who were on antiretroviral therapy had lower malaria prevalence. Prevalence of malaria for HIV-positive patients on antiretroviral therapy during the three-year period was 12% (12,929) as compared to 44% prevalence among HIV-positive patients not on antiretroviral therapy (47,109). The average number of times a patient on antiretroviral therapy presented with malaria significantly reduced by 23 times compared to the number of times HIV-positive patients not on antiretroviral therapy.

A study in Malawi from 2002 to 2005 compared monthly doses of Sulfadoxine- Pyrimethamine (SP) Intermittent Preventive Treatment (IPTp) from initiation to delivery with a 2-dose treatment of SP, at initiation and 28 weeks, to prevent placental malaria in 195 HIV-positive and in 303 HIV-negative pregnant women. The study found that monthly dosage proved more effective for HIV-positive women with only 7.8% having placental malaria at delivery compared to 21.5% of women who underwent the 2-dose regimen. Reduction in relative risk was similar for HIV-positive and HIV-negative women: for HIV-negative women, 2.3% receiving monthly SP and 6.3% receiving 2-dose SP had placental malaria, though the difference was not significant. Adverse drug reactions were reported in less than 1% of women. During the study combination antiretroviral therapy was not routinely available in Malawi.

A hospital-based study in Kenya followed 157 women ages 15-40 with vaginal deliveries and found placental malaria in 17.2% of infants and congenital malaria in 0% of infants by microscopy, while PCR detected 33.1% and 10.8%, respectively.