title: Incidence of malaria-related fever and morbidity due to Plasmodium falciparum among HIV1-infected pregnant women: a prospective cohort study in South Benin.
abstract: BACKGROUND
  Malaria and HIV are two major causes of morbidity and mortality among pregnant women in sub-Saharan Africa. Foetal and neonatal outcomes of this co-infection have been extensively studied. However, little is known about maternal morbidity due to clinical malaria in pregnancy, especially malaria-related fever, in the era of generalized access to antiretroviral therapy and anti-malarial preventive strategies.
  
  
  METHODS
  A cohort study was conducted in order to estimate the incidence rate and to determine the factors associated with malaria-related fever, as well as the maternal morbidity attributable to malaria in a high-transmission setting of South Benin among HIV-infected pregnant women. Four-hundred and thirty-two women who participated in a randomized trial testing strategies to prevent malaria in pregnancy were included and followed until delivery, with at least three scheduled visits during pregnancy. Confirmed malaria-related fever was defined as axillary temperature >37.5°C and a concomitant, positive, thick blood smear or rapid diagnostic test for Plasmodium falciparum. Suspected malaria-related fever was defined as an axillary temperature >37.5°C and the concomitant administration of an anti-malarial treatment in the absence of parasitological investigation.
  
  
  RESULTS
  Incidence rate for confirmed malaria-related fever was of 127.9 per 1,000 person-year (PY) (95% confidence interval (CI): 77.4-211.2). In multivariate analysis, CD4 lymphocytes (Relative Risk (RR) for a 50 cells/mm3 variation = 0.82; CI: 0.71-0.96), antiretroviral treatment started before inclusion (RR = 0.34; CI: 0.12-0.98) and history of symptomatic malaria in early pregnancy (RR = 7.10; CI: 2.35-22.49) were associated with the incidence of confirmed or suspected malaria-related fever. More than a half of participants with parasitaemia were symptomatic, with fever being the most common symptom. The crude fraction of febrile episodes attributable to malaria was estimated at 91%.
  
  
  CONCLUSIONS
  This work highlights that malaria is responsible for a substantial morbidity in HIV-infected pregnant women, with cellular immunodepression as a major determinant, and establishes the possible advantage offered by the early initiation of antiretroviral treatment.
  
  
  BACKGROUND
  PACOME Study has been registered under the number NCT00970879.
authors.affiliation: UMR 216, Institut de Recherche pour le Développement, Paris, France. alex.duvignaud@gmail.com.
authors.forename: Alexandre
authors.initials: A
authors.lastname: Duvignaud
authors.forename: Lise
authors.initials: L
authors.lastname: Denoeud-Ndam
authors.forename: Jocelyn
authors.initials: J
authors.lastname: Akakpo
authors.forename: Komlan V
authors.initials: KV
authors.lastname: Agossou
authors.forename: Aldric
authors.initials: A
authors.lastname: Afangnihoun
authors.forename: Didier G
authors.initials: DG
authors.lastname: Komongui
authors.forename: Félix
authors.initials: F
authors.lastname: Atadokpédé
authors.forename: Lucien
authors.initials: L
authors.lastname: Dossou-Gbété
authors.forename: Pierre-Marie
authors.initials: PM
authors.lastname: Girard
authors.forename: Djimon-Marcel
authors.initials: DM
authors.lastname: Zannou
authors.forename: Michel
authors.initials: M
authors.lastname: Cot
mesh_terms: D000328:Adult; D001541:Benin / Q000453:epidemiology; D015331:Cohort Studies; D005260:Female; D015658:HIV Infections / Q000150:complications*; D006801:Humans; D015994:Incidence; D016778:Malaria, Falciparum / Q000453:epidemiology*; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000453:epidemiology*; D011446:Prospective Studies; D055815:Young Adult