Insights into Malaria and HIV Co-infection: Trends and Impact in Sub-Saharan Africa.

Malaria and HIV are the two most important infectious diseases and have comparable global disseminations. Given the eclectic geographical overlap on occurrence and the resulting co-infection; the interaction between the two diseases clearly has major public health implications, mostly in Sub-Saharan Africa. This study investigated the immunological alterations associated with HIV and Malaria co-infection in HIV positive individuals. The study was performed by sampling 600 adult HIV patients who routinely visit the General Hospital North-Bank Makurdi, Benue State, Nigeria. Blood samples were obtained for blood film microscopy identification of malaria parasites. Screening for immunological profiles was performed using the flow cytometer for the quantification of CD4+ cell count. Results: Of the 600 patients sampled, 221(36.8%) had normal CD4+ count (≥500cell/mm3), 320 (53.3%) had moderate CD4+ count (between 200 and 499cell/mm3) while 59 (9.8%) had poor CD4+ (less than 200cell/mm3). The mean CD4+ lymphocyte count of HIV-malaria co-infected patients was lower than HIV mono-infected patients. Malaria and HIV co-infection significantly reduced the CD4+ count of the subjects. In general, to achieve better management of all HIV patients in this setting, diagnosing malaria, prompt antiretroviral therapy, monitoring CD4 and some haematological indices on regular basis is important. In light of the epidemiological connection and global reputation of the two diseases, there is an urgent need for more research on a wider range in order to elucidate the impact of co-infection on host immune dynamics in HIV co-infected individuals.

Background: Studies from sub-Saharan Africa where malaria is endemic have observed high incidences of malaria and HIV co-infection. It has long been accepted that malaria causes alterations in haemostatic parameters and that HIV is associated with a wide range of haematological changes. We assessed the effect of the overlap of these infections on routine haemostatic parameters.Method: The study involved 337 subjects grouped according to their HIV and malaria status: Group 1 ‘Asymptomatic HIV seropositive, Plasmodium falciparum positive’ (n = 61); Group 2 ‘Asymptomatic HIV seropositive, P. falciparum negative’ (n = 73); Group 3 ‘Symptomatic HIV seropositive, P. falciparum positive’ (n = 49); Group 4 ‘Symptomatic HIV positive P. falciparum negative’ (n = 56); Group 5 ‘Control HIV negative, P. falciparum positive’ (n = 52) and Group 6 ‘Control HIV negative, P. falciparum negative’ (n = 46). Blood samples were taken for HIV testing, diagnosis of falciparum malaria and malaria parasite density counts. Citrated samples were used within one hour of collection for prothrombin time (PT) and activated partial thromboplastin time (APTT). CD4+ T cell counts, platelet count and haematocrit (Hct) were also performed.Results: Our results demonstrate greater alterations in APTT, PT and platelet count with prolongation of APTT, PT and lower platelet counts in HIV and malaria co-infection. In spite of this, the co-infected subjects with mild to moderate parasitaemia did not show a bleeding tendency; however, the risk is higher in severe malaria.Conclusion: These results suggest that co-infected subjects with severe malaria have a higher risk of bleeding and would require greater monitoring.

This study determined the effects of malaria parasite and HIV infection on malondialdehyde (MDA), serum iron (Fe) and some enzymes activities of pregnant women in Abeokuta, Ogun State. A total of 251 pregnant women were enrolled for the study. Blood samples were collected from each consented pregnant women during ante-natal clinic for malaria test, HIV screening, MDA, Fe, gluthathione-S-transferases (GST), superoxides-dismutase (SOD) and peroxidase (PERO). The prevalence of malaria parasite infection and HIV in the study was 28.3% and 16.4%, respectively, while co-infection occurred in 8% of the population. Malaria prevalence increased with decrease in CD4 count. Though, HIV and malaria as single infection increased MDA and reduced serum iron values in the pregnant women (p < 0.05), MDA values were significantly higher (p < 0.05) in pregnant women with HIV and malaria co-infection. Reduction in SOD value was recorded in those with malaria and HIV co-infection but increased in other groups (p < 0.05). Serum PERO titer value in pregnant women with HIV and malaria co-infection was significantly lower (p < 0.05) compared with pregnant women infected with either HIV or Malaria. These results showed varying degrees of HIV and malaria-related oxidative stress in pregnant women.

HIV and malaria co-infection: interactions and consequences of chemotherapy

Malaria and HIV co-infection in pregnancy in sub-Saharan Africa: impact of treatment using antimalarial and antiretroviral agents

BackgroundMalaria and HIV co-infection adversely impact the outcome of both diseases and previous studies have mostly focused on falciparum malaria. Plasmodium vivax contributes to almost half of the malaria cases in India, but the disease burden of HIV and P. vivax co-infection is unclear.MethodsHIV-infected subjects (n=460) were randomly selected from the 4,611 individuals seen at a Voluntary Counseling and Testing Center in Chennai, India between Jan 2 to Dec 31 2008. Malaria testing was performed on stored plasma samples by nested PCR using both genus-specific and species-specific primers and immunochromatography-based rapid diagnostic test for detecting antibodies against Plasmodium falciparum and P. vivax.ResultsRecent malaria co-infection, defined by the presence of antibodies, was detected in 9.8% (45/460) participants. Plasmodium vivax accounted for majority of the infections (60%) followed by P. falciparum (27%) and mixed infections (13%). Individuals with HIV and malaria co-infection were more likely to be men (p=0.01). Between those with and without malaria, there was no difference in age (p=0.14), CD4+ T-cell counts (p=0.19) or proportion CD4+ T-cell below 200/mL (p=0.51).ConclusionsRetrospective testing of stored plasma samples for malaria antibodies can facilitate identification of populations with high rates of co-infection, and in this southern India HIV-infected cohort there was a considerable burden of malaria co-infection, predominantly due to P. vivax. However, the rate of P. falciparum infection was more than 6-fold higher among HIV-infected individuals than what would be expected in the general population in the region. Interestingly, individuals co-infected with malaria and HIV were not more likely to be immunosuppressed than individuals with HIV infection alone.

Prevalence of malaria and HIV coinfection and influence of HIV infection on malaria disease severity in population residing in malaria endemic area along the Thai–Myanmar border

Malaria and HIV co-infection presents a significant public health challenge, particularly in Sub-Saharan Africa, where co-morbidity rates are highest. Conventional therapies, including antiretrovirals and antimalarial drugs, are expensive and often associated with side effects that lead to noncompliance. Traditional medicinal plants offer an affordable and culturally accepted alternative. This review explores various plants used historically in the treatment of both malaria and HIV, focusing on their phytochemical constituents, mechanisms of action, and clinical efficacy. Plants such as Catharanthus roseus, Adenia venenata, and Morinda lucida have demonstrated antimalarial and antiviral properties, often through bioactive compounds like alkaloids and flavonoids. Additionally, integrating these traditional medicines with modern healthcare systems faces regulatory challenges, but there is promising potential for synergies in treatment efficacy. Further research, clinical trials, and interdisciplinary collaboration are necessary to validate these medicinal plants and improve the management of malaria and HIV co-infection. Keywords: Traditional medicinal plants, Malaria, HIV co-infection, Phytochemicals, Antimalarial properties.

Tuberculosis (TB) is responsible for a substantial public health burden worldwide, with a heterogeneous geographical distribution. Sub-Saharan Africa accounts for almost one-quarter of the global burden of TB. This is associated with high HIV-prevalence, low socio-demographic development, and poor living and working conditions. Identification of high-risk populations and locations within countries with a high burden of TB has the potential to improve the cost-effectiveness of TB control strategies.Two groups of 30 countries account for almost 90 per cent of the global burden of TB disease and TB and HIV co-infection. Ethiopia is in both groups, with both high-TB and TB and HIV co-infection. However, information is limited to the geographical distribution of high-risk areas which could inform targeted intervention. The overall aim of the researches in this Thesis is to enhance the TB control program in Ethiopia by providing more detailed knowledge of the distribution of TB, and the contributory role of HIV, low sociodemographic development and poor living and working conditions. This will provide sustained TB control in Ethiopia and enable enhanced strategic implementation of the “End TB strategy.”The first part (Chapters 1-3) of this Thesis highlights the available evidence on the geographical variation of TB and the burden of TB and HIV co-infection. Chapter 4 presents a systematic review of published studies on the effects of altitude and temperature on TB notification. This review indicated that studies examining the correlations between altitude and temperature on TB notification are limited in number. Despite low study power, the report demonstrated that living in low-altitude and high-temperature settings may increase TB risk.Chapter 5 presents evidence from a systematic review and meta-analysis conducted to estimate the prevalence of HIV in patients diagnosed with TB in sub-Saharan Africa. The prevalence of HIV in diagnosed TB patients (HIV/TB) showed substantial heterogeneity with an overall prevalence estimate of HIV/TB of 31.8 per cent. Heterogeneity in HIV/TB between studies was mainly attributable to geographic region and HIV prevalence. The Eastern and Southern sub-Saharan African region had a higher prevalence of HIV/TB (34.4 per cent) compared to Western and Central sub-Saharan Africa (27.3 per cent). However, the prevalence decreased more in the Eastern and Southern sub-Saharan African region than Western and Central sub-Saharan African between 2000 and 2010. This study suggests that collaborative TB and HIV activities need to be strengthened and sustained to achieve an end to the TB epidemic.Based on evidence from previous chapters, Chapters 6 and 7 present the spatial distributions of TB and HIV, profiling the sociodemographic and environmental determinants in the Amhara region of Ethiopia, using separate TB and HIV cluster detection methods. These studies demonstrated the spatial heterogeneity of both diseases. Both district-level TB notifications, reported between 2014 and 2017, and HIV infection rates, between 2015 and 2017, were spatially clustered in the border areas of the Amhara region of Ethiopia. Regression analyses demonstrated that the most important factor associated with both TB and HIV clustering was the proportion of seasonal migrant populations in the district. Additional factors associated with high notifications of TB were the proportion of people living in urban areas, crowding, the percentage of males, people living with HIV (PLHIV) /1000 population, access to health care, and the use of charcoal for cooking. Living at low altitude was also associated with TB clustering, which was consistent with the review findings in Chapter 4. Low educational status was also associated with HIV high-risk areas.Chapter 8 presents the epidemiology of TB and HIV co-infection in Ethiopia. This chapter elucidates the progress of the implementation of collaborative TB and HIV activities and the consequent impact on the national TB control program. Findings from sentinel surveillance of TB and HIV co-infection data, from 76 health facilities in Ethiopia, suggest that collaborative TB and HIV services were either not uniform or not consistently implemented between 2010 and 2015. However, encouragingly, intensified TB case finding in PLHIV and the screening of HIV patients for TB diagnosis increased. This Thesis provides more detailed evidence on the distribution of TB and associated HIV infection in Ethiopia, using geo-spatial tools and modelling. It shows that TB and HIV infection are geographically heterogeneous and co-clustered in the Northwest border areas of Ethiopia, likely influenced by the proportion of seasonal migrants in common. This information provides the basis to enhance the strategic implementation of TB control program in Ethiopia. It also highlights the need to strengthen integrated TB and HIV management, to address social determinants of TB, and to deal with issues of population movement to control and prevent HIV and TB in Ethiopia, and thus achieve the “End-TB” goal.

Co-infection of malaria and HIV often result in a precarious switch of the immune reaction from T-helper 1 (Th-1) - type 1 to type 2 or vice versa. Immunological status are seriously threatened in the case of infection by HIV and Plasmodium falciparum or both in pregnant mother, hence the need to investigate the immunological responses at different status of infections. A total of 149 mothers were recruited in a longitudinal study in the endemic area of Saki. Rapid diagnostic tested kits were used for HIV diagnosis in mother; CD4+ counts were enumerated by using FACS count techniques. Four cytokines were profiled TNF-α, IL-2, IL-10 and IFN-γ by Enzyme Linked Immunosorbent Assay. The data generated were analyzed using appropriate method. The prevalence of malaria in mothers was 85/149 (57.1%); a higher mean parasite density of 340×103 parasite/μL of blood was observed in multigravidae than in secundigravidae with 195×103 parasite/μL of blood and 265×103 parasite/ of blood in primigravidae, there was no significant relation between parity and parasite density in the participating mothers. The HIV and malaria was (22.8%) in mothers while the co infection of HIV and sero-prevalence was (30.2%). The CD4+ counts below WHO recommended were observed in 46.9, 33.4 and 47.1% HIV positive, malaria positive and co-infection mothers respectively. However, the concentration differentials of TNF-α, IL-10, IL-2 and IFN-γ in sero-positive mothers were-0.025, -0.0102, +0.0357 and 0.0255 pg/µL respectively. The CD4- T-lymphocytes counts, predominance of Th2 and proportion of co-infection mothers suggest significant health risk.

Background:The most challenging issue physicians are facing is the appropriate timing of introducing antiretroviral therapy (ART) along with ongoing tuberculosis (TB) therapy in HIV and TB co-infected patients. This study examined the cost-effectiveness of early versus delayed ART initiation in TB patients, infected with HIV (co-infected patients) in a sub-Saharan Africa setting. Methods:A decision analytic model based on previously published and real-world evidence was applied to evaluate clinical and economic outcomes associated with early versus delayed ART in TB and HIV co-infection. Incremental cost-effectiveness ratio (ICER) was calculated with both costs and quality-adjusted life years (QALYs). Different assumptions of treatment benefits and costs were taken to address uncertainties and were tested with sensitivity analyses. Results:In base case analysis, the expected cost of giving early ART to TB patients infected with HIV was $1372, with a QALY gain of 0.68, while the cost of delayed ART was $955, with a QALY gain of 0.62. The ICER shows $6775 per QALYs, which suggests that it is not as cost-effective, since it is greater than 3 x GDP per capita ($5,086) for sub-Saharan Africa willingness to pay (WTP) threshold. At $10,000 WTP, the probability that early ART is cost effective compared to delayed ART is 0.9933. At cost-effectiveness threshold of $5086, the population expected value of perfect information becomes substantial (≈US$5 million), and is likely to exceed the cost of additional investigation. This suggests that further research will be potentially cost-effective. Conclusions:From the perspective of the health-care payer in sub-Saharan Africa, early initiation of ART in HIV and TB co-infection cannot be regarded as cost-effective based on current information. The analysis shows that further research will be worthwhile and potentially cost-effective in resolving uncertainty about whether or not to start ART early in HIV and TB co-infection.

Introduction: Typhoid and malaria are significant causes of morbidity and mortality, especially in sub-Saharan Africa. Typhoid and malaria co-infection may occur as superinfection or even simultaneous infections. However, it appears to be rather rare. It is imperative to make an accurate diagnosis of typhoid and malaria co-infection. The study set out to determine the practice among healthcare workers in the diagnosis and treatment of typhoid and malaria co-infection.Methods: This descriptive cross-sectional study was carried out in Jos North Local Government Area in North-Central Nigeria. The sample population consisted of health care workers (HCWs) who were involved in the management of typhoid and malaria. Data were analysed using STATA version 14.0 College station, Boston, USA.Results: Seventy-five HCWs were interviewed. Typhoid and malaria were diagnosed by 67 (89%) HCWs at least once weekly, and by the other 11% at least once every month. The Widal test was used to make a diagnosis of typhoid in greater than 70% of the cases. There was no statistical difference in the rate of typhoid diagnoses between medical doctors and other HCW.Conclusion: There is a high rate of false diagnosis of malaria and typhoid co-infection. This informs the crucial need for quality training and re-training of health care workers in the diagnosis of these conditions. Keywords: False, typhoid, malaria, co-infection

Malaria and HIV/AIDS are among the principal causes of morbidity and mortality worldwide, particularly in resource-limited settings such as sub-Saharan Africa. Despite the international community’s efforts to reduce incidence and prevalence of these diseases, they remain a global public health problem. Clinical manifestations of malaria may be more severe in HIV infected patients, which have higher risks of severe malaria and malaria related death. Co-infected pregnant women, children and international travelers from non-malaria endemic countries are at higher risk of clinical complications. However, there is a paucity and conflicting data regarding malaria and HIV co-infection, particularly on how HIV infection can modify the response to antimalarial drugs and about drug-interactions between antiretroviral agents and artemisinin-based combined regimens. Moreover, consulting HIV-infected international travelers and physicians specialized in HIV care and travel medicine should prescribe an adequate chemoprophylaxis in patients travelling towards malaria endemic areas and pay attention on interactions between antiretrovirals and antimalarial prophylaxis drugs in order to prevent clinical complications of this co-infection.This review aims to evaluate the available international literature on malaria and HIV co-infection in adults providing a critical comprehensive review of nowadays knowledge.

Malaria and HIV, two of the world’s most deadly diseases, are widespread, but their distribution overlaps greatly in sub-Saharan Africa. Consequently, malaria and HIV coinfection (MHC) is common in the region. In this paper, pertinent publications on the prevalence, impact, and treatment strategies of MHC obtained by searching major electronic databases (PubMed, PubMed Central, Google Scholar, ScienceDirect, and Scopus) were reviewed, and it was found that the prevalence of MHC in SSA was 0.7%–47.5% overall. Prevalence was 0.7%–47.5% in nonpregnant adults, 1.2%–27.8% in children, and 0.94%–37% in pregnant women. MHC was associated with an increased frequency of clinical parasitemia and severe malaria, increased parasite and viral load, and impaired immunity to malaria in nonpregnant adults, children, and pregnant women, increased in placental malaria and related outcomes in pregnant women, and impaired antimalarial drug efficacy in nonpregnant adults and pregnant women. Although a few cases of adverse events have been reported in coinfected patients receiving antimalarial and antiretroviral drugs concurrently, available data are very limited and have not prompted major revision in treatment guidelines for both diseases. Artemisinin-based combination therapy and cotrimoxazole are currently the recommended drugs for treatment and prevention of malaria in HIV-infected children and adults. However, concurrent administration of cotrimoxazole and sulfadoxine–pyrimethamine in HIV-infected pregnant women is not recommended, because of high risk of sulfonamide toxicity. Further research is needed to enhance our understanding of the impact of malaria on HIV, drug–drug interactions in patients receiving antimalarials and antiretroviral drugs concomitantly, and the development of newer, safer, and more cost-effective drugs and vaccines to prevent malaria in HIV-infected pregnant women.

Given the vast investments made in national immunization programmes (NIPs) and the significance of NIPs to public health, it is important to understand what influences the optimal performance of NIPs. It has been established that well-performing NIPs require enabling health systems. However, systematic evidence on how the performance of health systems impacts on NIPs is lacking, especially from sub-Saharan Africa. We conducted a qualitative systematic review to synthesize the available evidence on health systems constraints and facilitators of NIPs in sub-Saharan Africa, using human papillomavirus immunization programmes as a proxy. Fifty-four articles published between 2008 and 2018 were found to be eligible. Data extraction was guided by an analytical model on the interface between NIPs and health systems. A cross-cutting thematic analysis of the extracted data was performed. This systematic review provides evidence necessary for informing ongoing health systems strengthening initiatives in sub-Saharan Africa. There is evidence to suggest that NIPs in sub-Saharan Africa have surmounted significant health systems constraints and have achieved notable public health success. This success can be attributed to strong political endorsement for vaccines, clear governance structures and effective collaboration with global partners. Despite this, significant health systems constraints persist in service delivery, vaccine communication, community engagement, the capacity of the health workforce and sustainable financing. These constraints could derail further progress if not addressed through health systems strengthening efforts. There is a need to expand the research agenda to include the comprehensive evaluation of health systems constraints and facilitators of NIPs within sub-Saharan Africa.