Effects of trimethoprim-sulfamethoxazole and insecticide-treated bednets on malaria among HIV-infected Ugandan children.
BACKGROUND
Trimethoprim-sulfamethoxazole (TMP/SMX) prophylaxis and insecticide-treated bednets reduce malaria risk among HIV-infected adults. The efficacy of TMP/SMX may be diminished where antifolate resistance to malaria is high. We evaluated the efficacy of these interventions for malaria prevention among Ugandan children.


METHODS
We concurrently followed 300 HIV-infected children aged 1-10 years and a community-based cohort of 561 healthy children aged 1-11 years over 11 months in Kampala, Uganda. The HIV-infected children received TMP/SMX prophylaxis and insecticide treated bednets. In the community cohort, insecticide-treated bednets were introduced during the observation period. Children from both cohorts were followed using a standardized protocol to measure the incidence of malaria.


RESULTS
Only nine episodes of malaria were diagnosed among HIV-infected children (incidence = 0.07/person-year) in comparison with 440 episodes among children from the community (incidence = 0.90/person-year; P < 0.0001). The use of insecticide-treated bednets was associated with a 43% reduction in malaria incidence (P < 0.001), and a combination of TMP/SMX and use of insecticide-treated bednets with a 97% reduction in malaria incidence (P < 0.001). The prevalence of five mutations associated with antifolate resistance was high among malaria cases detected in both the HIV (100%) and community cohorts (75%). Malaria accounted for only 4% of febrile episodes in the HIV cohort in comparison with 33% in the community-based cohort (P < 0.0001).


CONCLUSIONS
In a malaria endemic area with a high level of molecular markers of antifolate resistance, the combined use of TMP/SMX prophylaxis and insecticide-treated bednets was associated with a dramatic reduction in malaria incidence among HIV-infected children.
Kamya
Moses R
MR
Makerere University Medical School, Kampala, Uganda. mkamya@infocom.co.ug
Gasasira
Anne F
AF
Achan
Jane
J
Mebrahtu
Tsedal
T
Ruel
Theodore
T
Kekitiinwa
Adeodata
A
Charlebois
Edwin D
ED
Rosenthal
Philip J
PJ
Havlir
Diane
D
Dorsey
Grant
G
D000962:Antimalarials / Q000627:therapeutic use*; D001512:Bedding and Linens; D016022:Case-Control Studies; D002648:Child; D002675:Child, Preschool; D005260:Female; D015658:HIV Infections / Q000453:epidemiology; D006801:Humans; D015994:Incidence; D007223:Infant; D007306:Insecticides / Q000627:therapeutic use*; D008137:Longitudinal Studies; D008288:Malaria / Q000453:epidemiology / Q000517:prevention & control*; D008297:Male; D015662:Trimethoprim, Sulfamethoxazole Drug Combination / Q000627:therapeutic use*; D014454:Uganda / Q000453:epidemiology
D000962:Antimalarials; D007306:Insecticides; D015662:Trimethoprim, Sulfamethoxazole Drug Combination