HIV and Malaria

I recently found a copy for the Sept 24th Archives of Internal Medicine in my outpatient clinic mailbox. I assume one of my attendings saw that there was a malaria article in this issue and passed it along…Brentlinger et al. at the University of Washington recently reviewed and compared the WHO, MSF, ICAP guidelines as well as the scientific literature for the management of malaria and AIDS co-infection in resource poor settings.

Below is a brief summary:

HIV Viral Load and Malaria

Acute malaria increases HIV viral load as much as one log and as long as eight weeks even after effective treatment. This is likely to cause increased HIV transmission, although this has not been tested by a prospective study.

CD4 count and Malaria

Malaria reduces the CD4 count (40 ul per year for each episode of acute malaria in HIV+ persons in an observational study), and successful treatment of malaria causes CD4 counts to increase in HIV+ patients. The clinical significance is obvious: acute malarial infections in an HIV+ patient receiving ART may cause misinterpretation of decreased CD4 as ART regimen failure.

Malaria incidence and severity in HIV infection

Prospective cohort studies have shown increased malaria incidence as CD4 counts decline in HIV+ adults in areas of stable malaria transmission. For example, in Uganda, one group has shown an odds ratio of 6.1 for clinical malaria in persons with CD4 500.

Response to anti-malarial treatment in HIV-infected patients

One study in Kenya showed that HIV positive individuals with CD4 <200 were more likely to fail malaria treatment with S/P than their HIV-negative counterparts (68% vs. 87.7%, P<0.001). One third of the treatment failures in the HIV+ group were due to re-infection. The clinical significance is that patients with HIV being treated for acute malaria must be followed closely to detect treatment failure.

The authors have the following comments on why HIV positive patients residing in malaria-endemic regions are often misdiagnosed and mismanaged:

1. Heterogeneous clinical presentations of HIV-related disease and malaria make clinical decisions difficult

2. Malaria may occur concurrently with OIs and adverse drug reactions

3. Simplified malaria treatment guidelines may lead to errors of commission and omission

4. There is inadequate evidence in the scientific literature to guide clinicians regarding concurrent administration of ART and anti-malarials.

5. Due to lack of access to appropriate labs, patients with AIDS in resource poor settings are at high risk of inappropriate anti-malarial treatment and another cause for their symptoms may be missed.

It’s a pretty hefty review with some recommendations at the end that are interesting.

Reference: Arch Intern Med. 2007 Sep 24;167(17):1827-36

-tmt