HIV/ Malaria/ TB
Slutsker L, Marston BJ. HIV and malaria: interactions and implications. Curr Opin Infect Dis 2007;20:3-10.
Slutsker and Marston summarise accumulating evidence of interactions between HIV and malaria and implications related to prevention and treatment of coinfection. HIV-infected persons are at increased risk for clinical malaria; the risk is greatest when immune suppression is advanced. Adults with advanced HIV may be at risk for failure of malaria treatment, especially with sulfa-based therapies. Malaria is associated with increases in HIV viral load that, while modest, may increase HIV progression or the risk of HIV transmission. Cotrimoxazole prophylaxis greatly reduces the risk of malaria in people with HIV; the risk can be further reduced with antiretroviral treatment and the use of insecticide treated mosquito nets. Increased numbers of doses of intermittent preventive (malaria) treatment during pregnancy can reduce the risk of placental malaria in women with HIV. The author concludes that interactions between malaria and HIV have important public health implications. People with HIV should use cotrimoxazole and insecticide treated mosquito nets. Malaria prevention is particularly important for pregnant women with HIV, although more information is needed about the best combination of strategies for prevention. In people with HIV, malaria diagnoses should be confirmed, highly effective drugs should be used for treatment, and possible drug interactions should be considered.
Editors’ note: Less attention has been focused on HIV and malaria than on HIV and tuberculosis but, as this article underscores, interactions can contribute to morbidity and mortality. Preventing malaria and effectively treating it in people living with HIV is important on both the individual and community levels.
Zachariah R, Harries AD, Manzi M, Gomani P, Teck R, Phillips M, Firmenich P. Acceptance of anti-retroviral therapy among patients infected with HIV and tuberculosis in rural Malawi is low and associated with cost of transport. PLoS ONE 2006;1:e121. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1762339
Zachariah and colleagues analysed data on newly registered HIV-positive tuberculosis (TB) patients systematically offered ART in a district hospital in rural Malawi in order to a) determine the acceptance of ART b) conduct a geographic mapping of those placed on ART and c) examine the association between "cost of transport" and ART acceptance. The authors performed a retrospective cross-sectional analysis on routine programme data for the period of February 2003 to July 2004. Standardized registers and patient cards were used to gather data. The place of residence was used to determine road distances to the Thyolo district hospital. Cost of transport from different parts of the district was based on the known cost for public transport to the road-stop closest to the patient's residence. Of 1290 newly registered TB patients, 1003 (78%) underwent HIV-testing of whom 770 (77%) were HIV-positive. 742 of these individuals (pulmonary TB = 607; extra-pulmonary TB = 135) were considered eligible for ART of whom only 101(13.6%) accepted ART. Cost of transport to the hospital ART site was significantly associated with ART acceptance and there was a linear trend in association between cost and ART acceptance (X2 for trend = 25.4, P<0.001). Individuals who had to pay 50 Malawi Kwacha (1 United States Dollar = 100 Malawi Kwacha, MW) or less for a one-way trip to the Thyolo hospital were four times more likely to accept ART than those who had to pay over 100 MW (OR 4.0, 95% CI 2.0-8.1, P<0.001). The authors conclude that ART acceptance among TB patients in a rural district in Malawi is low and associated with cost of transport to the centralized hospital based ART site. Decentralizing the ART offer from the hospital to health centres that are closer to home communities would be an essential step towards reducing the overall cost and burden of travel.
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