Effectiveness of co-trimoxazole to prevent Plasmodium falciparum malaria in HIV-positive pregnant women in sub-Saharan Africa: an open-label, randomized controlled trial.

BACKGROUND: Human immunodeficiency virus (HIV) and malaria during pregnancy cause substantial perinatal mortality. As co-trimoxazole (CMX) protects children and HIV-positive adults against malaria, we compared the effectiveness of daily CMX with sulfadoxine-pyrimethamine intermittent preventive treatment (IPT-SP) on malaria risk in HIV-positive pregnant women in a Plasmodium falciparum-endemic African area. METHODS: From January 2009 to April 2011, we included in a randomized noninferiority trial all HIV type 1-infected pregnant women (≤28 weeks' gestation, CD4 count ≥200 cells/µL, hemoglobin level ≥7 g/L) in 19 health centers in Togo. Women were randomly assigned to daily 800 mg/160 mg CMX, or IPT-SP. The primary outcome was the proportion of malaria-free pregnancies. Other outcomes included malaria incidence, parasitemia, placental malaria, anemia, and infants' birth weight. RESULTS: Of 264 women randomly assigned to the CMX or IPT-SP group, 126 of 132 and 124 of 132, respectively, were included in the analysis. There were 33 confirmed cases of clinical malaria among 31 women in the CMX group, and 19 among 19 women in the IPT-SP group. Ninety-five of 126 (75.4%) women in the CMX group and 105 of 124 (84.7%) in the IPT-SP group remained malaria-free during their pregnancy (difference, 9.3%; 95% confidence interval [CI], -.53 to 19.1, not meeting the predefined noninferiority criterion). The incidence rate in intention-to-treat analysis was 108.8 malaria episodes per 100 person-years in CMX (95% CI, 105.4-112.2) and 90.1 in IPT-SP (95% CI, 86.8-93.4) (not significant). Prevalence of parasitemia was 16.7% in the CMX group vs 28% in the IPT-SP group (P = .02). Histology revealed 20.3% placental malaria in the CMX group vs. 24.6% in the IPT-SP group (not significant). Grade 3-4 anemia was more frequent in the CMX group (10% vs 4%; P = .008). No pregnant women died. Median birth weight was similar. CONCLUSIONS: Daily CMX was not noninferior to IPT-SP for preventing maternal malaria but safe and at least similar regarding parasitemia or placental malaria and birth outcomes. Clinical Trials Registration ISRCTN98835811.

[Hospitalization charges for patients in the Neurology Department of Lomé Teaching Hospital]. / Prix de revient d'une hospitalisation dans le service de neurologie du CHU de Lomé (Togo).

For many years the cost of health care in sub-Saharan Africa was largely covered by the State. But in September 1987, in view of the economical problems those countries had to face, the WHO regional committee adopted the "Bainako's Initiative" resolution. This meant that from then on everybody was to pay for their health expenses. The purpose of this prospective study which was conducted from March 1, 1996 to February 28, 1999 among 316 patients was to assess hospitalization charges incurred for patients in the Neurology Department of Lomé Teaching Hospital with a view to improve the quality of the services provided and the accessibility of care. A questionnaire was used and every expense relating to the hospitalization of each patient was recorded on a daily basis. The average cost is 389,586 (48,485 FCFA for an average stay of 19.7 (2.5 days. This average cost is 19 times the minimal monthly salary of a state employee. It can be broken down as follows: Accommodation costs represent 52%, medical acts and tests 20.3% while drug costs amount to 21.2% and accompanist expenses represent 6.5%. The average cost of HIV-infected patients is 635,017 (190,624 FCFA for an average stay of 57 (12.9 days. The average cost of HIV-negative patients is 257,354 (12,837 FCFA for an average stay of 24.4 (1.8 days. To improve the quality of the services and the accessibility of care, it is necessary to prescribe and make drugs available in their generic form. After a few days in hospital, some disabling diseases as strokes, myelopathy and myopathy should be treated at home to reduce the length of stay in hospital or in cheaper places such as prolonged accommodation centres.