THE BURDEN OF CO-INFECTION WITH HUMAN IMMUNODEFICIENCY VIRUS TYPE 1 AND MALARIA IN PREGNANT WOMEN IN SUB-SAHARAN AFRICA

TLDR

HIV and malaria are major causes of morbidity in sub‑Saharan African pregnancy, and despite 15 years of research, their complex interaction and the need for stronger prevention measures remain incompletely understood. The review examined how HIV hampers pregnant women’s control of malaria parasitemia and highlighted the urgent need for further studies on antiretroviral, cotrimoxazole, and antimalarial interactions. The authors conducted a literature review of studies since the first report 15 years ago on HIV’s effect on malaria parasitemia control in pregnancy. The review found that HIV‑infected pregnant women experience higher peripheral and placental malaria, greater parasite densities, more febrile illnesses, severe anemia, and adverse birth outcomes, shifting malaria risk to all gravidity groups and increasing malaria prevalence by 5.5–18.8 % in populations with 10–40 % HIV prevalence, while maternal malaria also doubles HIV‑1 viral loads.

Abstract

In sub-Saharan Africa, human immunodeficiency virus (HIV) and malaria are among the leading causes of morbidity during pregnancy. We reviewed available information collected since the first report 15 years ago that HIV impaired the ability of pregnant women to control malaria parasitemia. Results from 11 studies showed that HIV-infected women experienced consistently more peripheral and placental malaria (summary relative risk = 1.58 and 1.66, respectively), higher parasite densities, and more febrile illnesses, severe anemia, and adverse birth outcomes than HIV-uninfected women, particularly in multigravidae. Thus, HIV alters the typical gravidity-specific pattern of malaria risk by shifting the burden from primarily primigravidae and secundigravidae to all pregnant women. The proportional increase of malaria during pregnancy attributable to HIV was estimated to be 5.5% and 18.8% for populations with HIV prevalences of 10% and 40%, respectively. Maternal malaria was associated with a two-fold higher HIV-1 viral concentrations. Three studies investigating whether placental malaria increased mother-to-child HIV-1 transmission showed conflicting results, possibly reflecting a complex balance between placental malarial immune responses and stimulation of HIV-1 viral replication. Further investigations of interactions between antiretroviral drugs, prophylaxis with cotrimoxazole, and antimalarial drugs in pregnant women are urgently needed. Although much has been learned in the past 15 years about the interaction between malaria and HIV-1 during pregnancy, many issues still require further information to improve our understanding. There is a clear need to strengthen the deployment of existing malaria and HIV prevention and intervention measures for pregnant women.