ABSTRACT
Background: Malaria and HIV-1 infection cause significant morbidity and mortality in sub-Saharan Africa. HIV-1 increases risk for malaria with the risk increasing as immunity declines.The effect of HIV-1 infection on antimalarial treatment outcome is still inconclusive. Objective: To compare antimalarial treatment outcome among HIV-1 positive and negative patients with acute uncomplicated falciparum malaria treated with chloroquine plus sulfadoxine-pyrimethamine (CQ+SP). Methods: Ninety eight HIV-1 positive patients aged 18 months or older with acute uncomplicated falciparum malaria were treated with CQ+SP and followed for 28 days to monitor outcome.Treatment outcome of HIV-1 positive patients was compared to that of 193 HIV-1 negative historical controls.The primary study outcome for both groups was treatment failure. Results: HIV-1 positive patients older than 5 years of age were less likely to have treatment failure compared to HIV-1 negative patients in the same age group (RR 0.59 95CI 0.4- 0.8; p a 0.001) and HIV-1 positive patients on routine cotrimoxazole prophylaxis were less likely to have treatment failure following CQ+SP treatment compared to HIV negative patients (RR 0.6 95CI 0.43-0.92; p = 0.006).There was no difference in treatment outcome according to HIV-1 status for children younger than 5 years of age. Conclusions: Adherence to cotrimo-xazole prophylaxis should be reinforced in HIV positive patients and it should be reassessed if these patients present with acute episodes of malaria
Subject(s)
HIV Infections , Malaria/therapy , Treatment OutcomeABSTRACT
Background: Despite global effort to scale up access to antiretroviral therapy (ART); many people in need of HIV/AIDS care in Uganda have not been reached. HIV testing and ART are not widely offered as routine medical services and data on HIV/AIDS in emergency settings in Sub-Saharan Africa is limited.We determined the HIV prevalence and eligibility for ART in a medical emergency unit at Mulago hospital. Methods: In a cross-sectional study; we interviewed 223 patients who were systematically selected from the patients'register from October through December 2004. HIV testing was offered routinely and results were delivered within 30 minutes.We evaluated HIV infected patients for WHO clinical stage of disease and referred them for HIV/AIDS care. Results: Out of 223 patients; 111 (50) had HIV infection of whom 78 (70) had WHO clinical stage 3 and 4 of disease thereby requiring ART. Overall; 84 out of 111 (76) HIV positive patients had not received any specific HIV/AIDS care. Conclusion: The burden of HIV infection in the medical emergency unit is high and majority of the patients who required ART had no prior HIV/AIDS care.We recommend scale up of HIV/AIDS care in acute care settings in order to increase access to ART
Subject(s)
HIV , Acquired Immunodeficiency Syndrome/therapy , Adult , Eligibility Determination , Emergency Medical Services , HospitalsABSTRACT
Background: Presumptive treatment of malaria in febrile children is widely advocated in Africa. This may occur in the absence of diagnostic testing or even when diagnostic testing is performed but fails to detect malaria parasites. Such over-treatment of malaria has been tolerated in the era of inexpensive and safe monotherapy. However; with the introduction of new artemisinin-based combination therapy (ACT); presumptive treatment becomes economically and clinically less acceptable. Methods: The risks and benefits of only treating children with microscopy confirmed malaria using a prospective cohort design were investigated. A representative sample of 601 children between one and 10 years of age were recruited from a census population in Kampala; Uganda and were followed for all of their health care needs in a study clinic. Standard microscopy was performed each time a child presented with a new episode of fever and antimalarial therapy given only if the blood smear was positive. Results: Of 5;895 visits for new medical problems 40were for febrile illnesses. Of the 2;359 episodes of new febrile illnesses; blood smears were initially reported as negative in 1;608 (68) and no antimalarial therapy was given. Six of these initially negative smears were reported to be positive following quality control reading of all blood smears: four of these patients were subsequently diagnosed with uncomplicated malaria and two cleared their parasites without antimalarial treatment. Of the 1;602 new febrile illnesses in which the final blood smear reading was classified as negative; only 13 episodes (0.8) were diagnosed with malaria in the subsequent 7 days. All 13 of these episodes of malaria were uncomplicated and were successfully treated.Conclusions: In this urban setting; malaria was responsible for only 32of febrile episodes. Withholding antimalarial therapy in febrile children with negative blood smears was safe and saved over 1;600 antimalarial treatments in 601 children over an 18-month period. In the era of expensive ACT; directing resources towards improving diagnostic and treatment practices may provide a cost-effective measure for promoting rational use of antimalarial therapy
Subject(s)
Child , Clinical Laboratory Techniques , Malaria/therapyABSTRACT
Increasing Plasmodium falciparum resistance to chloroquine in sub-Saharan Africa necessitates use of alternative antimalarial agents. Affordable alternative treatments inlude sulfadoxine/pyrimethamine and amodiaquine. Combination of antimalarial agents can increase thepeutic resistance. We compared the efficacy of sulfadoxine/pryrimethamine; amodiaquine; and an amodiaquine/sulfadoxine/pyrimethamine combination for treatment of uncomplicated malaria in a region of high chloroquine resistance. Methods: Patients with symptoms of uncomplicated falciparum malaria and confirmed disease in Kampala; Uganda; were randomly assigned to receive sulfadoxine/pyrimethamine) plus placebo; amodiaquine (25mg/kg) sulfadoxine and 1.25mg/kg prymethamine) plus placebo; or amodiaquine plus sulfadoxine/pyrimethamine. Patients were followed up for 14 days; and clinical and parasitological outcomes were assessed. Findings: 90(400/445) of patients enrolled in the study successfully completed 14 days of follow-up. Treatment failure based on clinical criteria occurred in 13 of 131 (10) patients on sulfadoxine/pyrimethamine. Based on parasitological criteria; treatment failed in 26; 16; and 10of these patients; respectively. Amodiaquine/sulfadoxine/pyrimethamine was significantly more effective than sulfadoxine/pyrimethamine alone in children aged younger than 5 years (clinical failure in 3.5vs 13.9; respectively; risk difference 10.4[95CI; 1.6-19.3] p=0.021; parasitological failure in 12.8vs 26.4; risk difference 13.61.2-26.0] p=0.041) Interpretation Sulfadoxine/pyrimethamine; amodiaquine; and amodiaquine/sulfadoxine/pyrimethamine were all effective for treatment of uncomplicated falciparum malaria in Uganda. The amodiaquine/sulfadoxine/pyrimethamine combination was the most effective; and could be the optimum low-cost alternative to chloroquine in Africa