Intermittent preventive treatment regimens for malaria in HIV-positive pregnant women

Abstract

Background
Intermittent preventive treatment is recommended for pregnant women living in malaria endemic countries due to benefits for both mother and baby. However, the impact may not be the same in HIV-positive pregnant women, as HIV infection impairs a woman's immunity.

Objectives
To compare intermittent preventive treatment regimens for malaria in HIV-positive pregnant women living in malaria-endemic areas.

Search strategy
In June 2011, we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL, MEDLINE; EMBASE; LILACS, the metaRegister of Controlled Trials (mRCT), reference lists and conference abstracts. We also contacted researchers and organizations for information on relevant trials.

Selection criteria
Randomized controlled trials comparing different intermittent preventive treatment regimens for preventing malaria in HIV-positive pregnant women in malaria-endemic areas.

Data collection and analysis
Two authors extracted data and assessed risk bias. Dichotomous variables were combined using risk ratios (RR) and mean differences (MD) for continuous outcomes, both with 95% confidence intervals (CI).

Main results
Two randomized trials with 722 HIV-positive pregnant women were included, comparing monthly regimens of sulfadoxine-pyrimethamine (SP) to the standard 2-dose regimen in the second and third trimesters. There were no statistically significant differences between monthly SP and 2-dose SP in rates of maternal anaemia, low birth weight, and neonatal mortality. In primigravidae and secondigravidiae, the monthly regimen was associated with less placental parasitaemia (RR 0.38, 95% CI 0.21 to 0.70, two trials) and less peripheral parasitaemia (RR 0.25, 95% CI 0.14 to 0.43, two trials), but no effect was demonstrated in multigravid women. Babies born to primigravidae and secundigravida women on monthly SP had a higher mean birth weight (weighted mean difference (WMD) 130 g; 95% CI 120 g to 150 g, two trials) than babies born to mothers on 2-dose SP. Multigravidae women treated with monthly SP had significant higher haemoglobin level than those treated with treated 2 dose SP (WMD 0.21 g/dL, 95% CI 0.15 g/dL to 0.27 g/dL, one trial). There were no trials that assessed other treatment regimens for intermittent preventive treatment in HIV-positive pregnant women.

Authors' conclusions
Three or more doses of SP is superior to the standard two doses in HIV-positive pregnant women. However, since SP cannot be administered concurrently with co-trimoxazole - a drug often recommended for infection prophylaxis in HIV-positive pregnant women, new drugs and research is needed to address needs of HIV-positive pregnant women.

Plain Language Summary - Drugs to prevent malaria in HIV-positive pregnant women.
Intermittent preventive treatment is the administration of a complete curative dose of an antimalarial medicine at predefined intervals during pregnancy (from the second trimester) regardless of whether or not the pregnant woman has malaria parasites. Intermittent preventive treatment for pregnant women, as is delivered at routine ante-natal care visits, is a World Health Organization (WHO) recommended policy and has been adopted in the majority of African malaria endemic countries. Since HIV increases the severity of malaria in pregnant women, it is important to evaluate the various drugs and doses needed to prevent malaria in HIV-positive pregnant women.

This review only identified two trials which compared the impact of using three or more doses of sulphadoxine-pyrimethamine to using only two doses. Using three or more doses was more effective at preventing the presence of malaria parasites in the placenta and in the peripheral blood of the pregnant woman than using the standard two doses only. Also, children born to HIV-positive pregnant women who used three or more doses of sulphadoxine-pyrimethamine weighed more than those born to mothers who used only the standard two doses.

Although more frequent doses of this drug are effective in preventing malaria, HIV-positive pregnant women with low CD4 count can not use the drug since the current policy requires that they use co-trimoxazole (bactrim) to prevent opportunistic infections. There is need, therefore, to investigate alternative drugs and regimens in preventing malaria in HIV-positive pregnant women.

Citation

Mathanga, D. P.; Uthman, O. A.; Chinkhumba, J. Intermittent preventive treatment regimens for malaria in HIV-positive pregnant women. Cochrane Database of Systematic Reviews (2011) (Issue 10) Art. No.: CD006689. [DOI: 10.1002/14651858.CD006689.pub2]

Intermittent preventive treatment regimens for malaria in HIV-positive pregnant women

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