World AIDS Day

"Malaria and HIV are two of the most devastating global health problems of our time. Together they cause more than 4 million deaths a year" (WHO). On this World AIDS Day, Infectious Bite looks at the relationship between malaria and HIV (the virus that causes AIDS), and discusses new research to treat co-infected (simultaneously infected with both diseases) individuals.

"Our current understanding of the human immune response to malaria and HIV leads us to expect that either infection might influence the clinical course of the other." Ordinarily, "infections are associated with at least a transient increase in HIV viral load" (measure of severity) and it is logical to assume that malaria accelerates "HIV disease progression." On the other side, "immune deficiency caused by HIV infection should, in theory, reduce the immune response to malaria parasitemia and therefore increase the frequency of clinical attacks of malaria" (Whitworth).

According to UNICEF, "HIV infection increases the incidence and severity of clinical malaria. In non-pregnant adults, HIV infection has been found to roughly double the risk of malaria parasitemia and clinical malaria...Although the effect of malaria on HIV has not been so well documented, some recent research is now adding to the growing body of evidence. Acute malaria infection increases viral load, and one study found that this increased viral load was reversed by effective malaria treatment. This malaria-associated increase in viral load could lead to increased transmission of HIV and more rapid disease progression, with substantial public health implications" (UNICEF).

Treatment of malaria is also complicated by HIV. "Artemisinin combination therapy has become the standard of care for uncomplicated malaria in most of Africa. However, there is limited data on the safety and tolerability of these drugs, especially in young children and patients co-infected with HIV" (Shereen). Recently, a "controlled trial was conducted" in Uganda consisting of "HIV-infected and uninfected children aged 4-22)." Participants were randomly designated to receive treatments of artemether-lumefantrine (AL) or dihydroartemisinin-piperaquine (DP). Both therapies were deemed "safe and well tolerated for the treatment of uncomplicated malaria in young HIV-infected and uninfected children" (Shereen).

In conclusion, co-infection of HIV and malaria fuels the spread of both diseases. HIV increases the severity of the episode and the patient susceptibility to malaria infection. Malaria increases the viral load of HIV, thereby elevating the risk of spreading HIV. "Co-infection might...have facilitated the geographic expansion of malaria in areas where HIV prevalence is high. Hence, transient and repeated increases in HIV viral load resulting from recurrent co-infection with malaria may be an important factor in promoting the spread of HIV in sub-Saharan Africa" (Abu). The connection between HIV and malaria also corresponds to the treatment of both diseases. Artemether-lumefantrine and dihydroartemisinin-piperaquine are safe for the treatment of malaria in HIV-infected children. It is also believed that the effective treatment of malaria within HIV-infected individuals may reverse the increased viral load of co-infected individuals.

SOURCES:
Abu-Raddad, Laith J. Et. Al. "Dual Infection with HIV and Malaria Fuels the Spread of Both Diseases in Sub-Saharan Africa". Science 8 December 2006.

Shereen, Katrak Anne. Et al. Malaria Journal 2009, 8:272
UNICEF. "Malaria and HIV/AIDS." http://www.unicef.org/health/files/UNICEFTechnicalNote6MalariaandHIV.doc

Whitworth, James. HIV InSite Knowledge Base Chapter. May 2006. http://hivinsite.ucsf.edu/InSite?page=kb-05-04-04

WHO. http://apps.who.int/malaria/malariandhivaids.html

Call to action

"In this week's PLoS Medicine, the journal's editors call for concerted international action to address the crisis of malaria drug shortages across Africa." Compared to activism for many other causes, anti-malaria offensives are still developing to find novel ways to fight the disease. Editors reveal the signs of "an evolving 'malaria activism' (akin to AIDS activism)" (Public). "Probably no other disease in human history has been associated with social and political activism to the extent that the HIV epidemic has" (AIDS Activism). "Such activism played a huge role in reducing the costs of antiretroviral drugs in developing countries" (PLoS). Five years ago, a strong voice "argued that similar activism was needed to raise awareness of shortfalls in global efforts to control malaria" (Yarney). "We believe there are now signs of an evolving "malaria activism," which has resulted in two major successes" (PLoS). These outspoken agents assert that two waves of malaria activism have already occurred, and that we stand on the break of a third wave which will help deliver life-saving drugs to those who need them.

According to the medical journal, the "first wave of malaria activism highlighted the gap between the huge burden of malaria and the tiny amount of international development assistance dedicated to its control. Such advocacy helped motivate donors to increase their malaria commitments." The second wave of activism "focused on making sure that the extra funding was used to purchase" combination therapy drugs (like artemisinin combination therapies) that are more effective in Africa than single drug therapies (like cholorquine).
"These are big victories," the editors declare. "But one benchmark of successful ACT [Artemisinin Combination Therapy] scale-up is whether the drugs are available at the point of care. One of us has just returned from a health reporting fellowship in East Africa, where he found that ACT 'stock-outs' (shortages) were common." This crisis is due in part to "inadequate funding" to purchase the necessary combination therapies, "delays in procuring the drug, and weak health information systems that can't properly track national drug needs and flows".
The editors of the medical journal call for action. It is time for a third wave of activism. This new wave will raise awareness of the shortages of necessary drugs in regions of the world where they are desperately needed.

Sources:
AIDS Activism. http://www.albany.edu/sph/AIDS/activists.html

PLoS. "Time for a Third Wave of Malaria Activism." http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000188

Public Library of Science. "It's Time for a 'Third Wave' of Malaria Activism to Tackle Drug Shortages." ScienceDaily 23 November 2009. 24 November 2009 .

Yarney, G. "Roll Back Malaria." http://www.plosmedicine.org/article/findArticle.action?author=Yamey&title=Roll%20Back%20Malaria:%20A%20failing%20global%20health%20campaign.