EDCTP-funded projects have identified ways to enhance two proven malaria prevention strategies, intermittent preventive treatment in pregnancy and seasonal malaria chemoprevention.
Intermittent preventive treatment of malaria in HIV-infected pregnant women
Malaria has multiple harmful consequences for both pregnant women and their babies. This is particularly the case for pregnant women living with HIV. Intermittent preventive treatment in pregnancy (iPTP) with sulphadoxine–pyrimethamine is recommended to protect women against malaria at this vulnerable time, but is not suitable for women living with HIV who are taking co-trimoxazole prophylaxis.
In the EDCTP-funded MAMAH project, Dr Raquel González, part of Professor Clara Menendez’s team at the Barcelona Institute for Global Health (ISGlobal), Spain, with colleagues in Gabon and Mozambique, has been assessing a possible alternative to sulphadoxine–pyrimethamine, dihydroartemisinin-piperaquine (DHA-PPQ), in a trial involving 666 pregnant women with HIV receiving antiretroviral therapy and co-trimoxazole prophylaxis.
The prevalence of maternal parasitaemia was unexpectedly low during the study period, so the primary endpoint was not met. However, a positive diagnostic test for Plasmodium was much reduced in the DHA-PPQ group, and no safety issues or interference with the HIV-related medications were identified. In a low-transmission setting, Dr González suggested, monthly iPTP combined with co-trimoxazole appears to be safe and reduces the risk of malaria infections in HIV-infected women during pregnancy.
Seasonal malaria chemoprevention in children
In settings where malaria mainly occurs during particular times of the year, seasonal malaria chemoprevention (SMC) with sulphadoxine–pyrimethamine and amodiaquine is known to be highly effective at reducing the burden of malaria. WHO recently recommended extending SMC to school-aged children and to use alternative artemisinin-based therapies. However, there are limited data on this use of ACTs and their potential to select for drug-resistant parasites.
Dr Karim Traore, Malaria Research and Training Center (MRTC-P), Université des Sciences, des Techniques et des Technologies de Bamako (USTTB), Bamako, Mali, and colleagues have assessed the efficacy of DHA-PPQ before and after SMC, and tracked the prevalence of resistance markers to ACT, amodiaquine and piperaquine.
A trial involving 345 school-aged children found that the prevalence of malaria parasites was reduced substantially after both types of SMC therapy. The project has also sequenced three genes associated with resistance to antimalarials, finding no concerning mutations in the DHFR gene (data on two other genes are still being analysed). The results suggest that DHA-PPQ is suitable for SMC in this group of children.
Nutritional supplementation to enhance SMC
In rural Africa, many of the children receiving SMC are under-nourished, so SMC campaigns are an opportunity also to deliver nutritional interventions.
In the EDCTP-funded SMC-NUT project, Dr Berenger Kabore, Institut De Recherche en Sciences de la Santé (IRSS)/ Clinical Research Unit of Nanoro (CRUN), Nanoro, Burkina Faso, working with EDCTP Fellow Dr Paul Sondo and colleagues, has been evaluating whether the addition of vitamin A supplementation to SMC, followed by either zinc supplementation or a high-calorie nutritional supplement (Plumpy’Doz), affects child survival.
In a trial of more than 1000 children in Burkina Faso, all-cause mortality was reduced by 24% by nutritional supplementation with Plumpy’Doz and uncomplicated malaria was reduced by 23%. Most strikingly, this supplementation reduced the risk of severe malaria by 52%. All-cause mortality was also significantly reduced. Dr Kabore suggested that the addition of nutritional supplementation to SMC could have a major impact on child survival and prevention of malaria.
Dr Hamtandi Magloire Natama, Institut de Recherche en Sciences de la Sante – Unité de Recherche Clinique de Nanoro (Burkina Faso): Associations between prenatal malaria exposure, maternal antibodies at birth and malaria susceptibility during the first year of life in Burkina Faso
Dr Bwendo Nduna, Arthur Davison Children’s Hospital (Zambia): High mortality in African infants living with HIV hospitalized with severe pneumonia
Dr David Moore, University of the Witwatersrand (South Africa): Receipt of intravenous co-amoxiclav challenges eligibility screening for the PediCAP Trial in Johannesburg, South Africa