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.

Authors' conclusions: 

Three or more doses of SP may have some advantages over the standard two doses in HIV-positive pregnant women, but larger trials would be necessary to confirm an effect on patient important outcomes. 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.

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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 were included, enrolling 722 HIV-positive pregnant women from Malawi and Zambia. Both compared monthly regimens of sulfadoxine-pyrimethamine (SP) to the standard 2-dose regimen given in the second and third trimesters.

In women in their first or second pregnancy, monthly SP may reduce both maternal parasitaemia (two trials, 463 participants, RR 0.25, 95% CI 0.14 to 0.43, low quality evidence), and placental parasitaemia at delivery (two trials, 459 participants, RR 0.38, 95% CI 0.21 to 0.70, low quality evidence). Monthly SP may have a small effect on the prevalence of maternal anaemia at delivery (two trials, 447 participants, RR 0.93, 95% CI 0.72 to 1.20, low quality evidence), and the number of babies born with low birth weight (two trials, 469 participants, RR 0.80, 95% CI 0.52 to 1.23, low quality evidence), but larger trials are necessary to reliably prove or exclude clinically important benefits on these outcomes. There is currently insufficient evidence to make conclusions regarding an effect on neonatal mortality (one study, 253 participants, very low quality evidence).

In women in their third or higher pregnancy, there is insufficient evidence to make any conclusions on the benefits of monthly SP compared to the two dose regimen (one trial, 166 participants, very low quality evidence).

There were no trials that assessed other treatment regimens for intermittent preventive treatment in HIV-positive pregnant women.

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