1. Module 7: Malaria and HIV/AIDS Palliative Care for People Living with HIV/AIDS

2. Module 7: Malaria and HIV/AIDS2 Learning Objectives  Describe the interactions between malaria and HIV.  Discuss strategies for preventing malaria as part of the palliative care package.  Implement strategies to treat malaria among people with HIV/AIDS.

3. Module 7: Malaria and HIV/AIDS3 Background  Malaria and HIV/AIDS are both endemic in Ethiopia: 50 million people are at risk for malaria. 9 million reported cases annually. Leading cause of morbidity and mortality. 0.9–3.5% HIV prevalence, 420,000, 1.3 million with HIV/AIDS  The most vulnerable groups for malaria and HIV/AIDS are similar: pregnant women, young children, the poor.  Coordinated service delivery can help prevention and treatment of both diseases. Source: UNICEF; FMOH, 2004; FMOH, 2006; UNAIDS, 2007

4. Module 7: Malaria and HIV/AIDS4 Impact of HIV/AIDS on Malaria  People with HIV/AIDS are more likely to have symptomatic malaria, severe malaria, and anemia.  Prevalence and density of placental and peripheral parasitemia are higher in HIV- infected pregnant women.  Pregnant women coinfected with HIV and malaria are at higher risk for anemia, preterm birth, and low birth weight infants.  Antimalarial treatment failure may be more common in people with low CD4 counts. Sources: Francesconi, et al, 2001; French, et al, 2001; Patnak, et al, 2005; ter Kuile, et al, 2004; Ayisi, et al, 2003

5. Module 7: Malaria and HIV/AIDS5 Impact of Malaria on HIV/AIDS  Long-term data are lacking  Acute malarial episodes cause a temporary increase in viral replication  Placental malaria may increase viral load Sources: Kublin, et al, 2005; Whitworth, et al, 2005

6. Module 7: Malaria and HIV/AIDS6

7. 7 Malaria Control and Prevention Strategies in Ethiopia  Rapid diagnosis and prompt treatment.  Selective vector control: ITN (Insecticide treated nets). IRS (indoor residual spray). Others: −Environmental modification. −Larviciding.  Early detection and containment of malaria epidemic.  Other strategies that work are intermittent presumptive treatment of pregnant women, pCTX, HAART.  Focus on children <5 years and pregnant women in endemic areas.

8. Module 7: Malaria and HIV/AIDS8 Uganda Study  Combination of: pCTX ART Treated nets  Associated with a 95% reduction in the incidence of symptomatic malaria among people with HIV/AIDS. Source: Mermin, et al, 2006

9. Module 7: Malaria and HIV/AIDS9 Insecticide-Treated Nets (ITNs)  In Africa, ITNs have been shown to reduce all cause mortality by 20%.  ITNs will have a public health impact if >80% of the population at risk uses them.  Pregnant women and children under five living in malarial areas are the top priority for ITN.  Application of insecticide (dipping) greatly enhances the protective efficacy of bed nets.  Long lasting nets are distributed in Ethiopia, which is advantageous because they don’t need pretreatment.

10. Module 7: Malaria and HIV/AIDS10 Malaria Treatment (1)  Use laboratory tests to diagnose malaria when possible. The Ethiopian guidelines recommend: Health post level: clinical or clinical + RDT Health center and hospital level: Microscopy Use laboratory tests in HIV-positive people whenever possible  HIV/malaria coinfected patients may show different clinical symptoms.  Look for and treat anemia.

11. Module 7: Malaria and HIV/AIDS11 Malaria Treatment (2)  Rapid treatment with artemisinin-based combination therapy (ACT). Contraindicated in children <5 kg and pregnant women.

12. Module 7: Malaria and HIV/AIDS12 Unanswered Questions  What is the impact of malaria on MTCT?  What are some interactions between antimalarial drugs and ARVs?  What is the relationship between pCTX and malaria? Note: Preventive therapy for pregnant women on pCTX not advised by WHO. What is the role of pCTX in preventing peripheral and placental malaria?

13. Module 7: Malaria and HIV/AIDS13 Key Points  Integration of malaria and HIV prevention and treatment activities is crucial.  People with HIV/AIDS are more likely to have symptomatic and severe malaria, and anemia.  Pregnant women and children with HIV/AIDS are most at risk for malaria.  Education on preventive measures and provision of ITNs is part of the HIV care package.  The use of ITNs, pCTX, and ART can greatly reduce malaria incidence in people with HIV.  Watch for interactions of ACT and ARVs.

14. Module 7: Malaria and HIV/AIDS14 Module 7 Wrap-Up