HIV This Week

Malamba S, Hladik W, Reingold A, Banage F, McFarland W, Rutherford G, Mimbe D, Nzaro E, Downing R, Mermin J. The effect of HIV on morbidity and mortality in children with severe malarial anaemia. Malar J 2007;6:143.

Malaria and HIV are common causes of mortality in sub-Saharan Africa. The effect of HIV infection on morbidity and mortality in children with severe malarial anaemia was assessed. In the study methods, children <5 years old were followed as part of a prospective cohort study to assess the transfusion-associated transmission of blood-borne pathogens at Mulago Hospital, Kampala, Uganda. All children were hospitalized with a diagnosis of severe malarial anaemia requiring blood transfusion. Survival to different time points post-transfusion was compared between HIV-infected and uninfected children.  Generalized estimating equations were used to analyse repeated measurement outcomes of morbidity, adjusting for confounders. Results showed that, of 847 children, 78 (9.2%) were HIV-infected. Median follow-up time was 162 days (inter-quartile range: 111, 169). Children living with HIV were more likely to die within 7 days (Hazard ratio [HR] = 2.86, 95% Confidence interval [CI] 1.30-6.29, P=0.009) and within 28 days (HR = 3.70, 95% CI 1.91-7.17, P<0.001) of an episode of severe malarial anaemia, and were more likely to die in the 6 months post-transfusion (HR = 5.70, 95% CI 3.54-9.16, P<0.001) compared to HIV-uninfected children.  Children living with HIV had more frequent re-admissions due to malaria within 28 days (Incidence rate ratio (IRR) = 3.74, 95% CI 1.41-9.90, P = 0.008) and within 6 months (IRR = 2.66, 95% CI 1.17 - 6.07, P = 0.02) post-transfusion than HIV-uninfected children. In conclusion, children living with HIV with severe malarial anaemia suffered higher all-cause mortality and malaria-related mortality than HIV-uninfected children. Children with HIV and malaria should receive aggressive treatment and further evaluation of their HIV disease, particularly with regard to cotrimoxazole prophylaxis and antiretroviral therapy.

Editors’ note: Repeated childhood exposures to malaria act on cellular immune function to generate partial immunity. Impaired cellular immunity due to HIV infection impedes clearance of malaria parasites and increases the risk of complications requiring hospitalization. With 90% of the world’s children living with HIV residing in Africa, many in malaria endemic areas, action is required to initiate cotrimoxazole prophylaxis at birth for all babies born to HIV-positive mothers, to educate parents about febrile episodes in their HIV-infected children, and to ensure that they benefit from the insecticide-treated bed nets that reduce malaria by 50%.