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close this bookGuidelines for the Treatment of Malaria (WHO; 2006; 266 pages) View the PDF document
View the documentGlossary
View the documentAbbreviations
open this folder and view contents1. Introduction
View the document2. The clinical disease
open this folder and view contents3. Treatment objectives
open this folder and view contents4. Diagnosis of malaria
open this folder and view contents5. Resistance to antimalarial medicines9
open this folder and view contents6. Antimalarial treatment policy
close this folder7. Treatment of uncomplicated P. Falciparum malaria10
View the document7.1 Assessment
View the document7.2 Antimalarial combination therapy
View the document7.3 The choice of artemisinin-based combination therapy options
View the document7.4 Practical aspects of treatment with recommended ACTs
View the document7.5 Incorrect approaches to treatment
View the document7.6 Additional aspects of clinical management
View the document7.7 Operational issues in treatment management
View the document7.8 Management of treatment failures
View the document7.9 Treatment in specific populations and situations
View the document7.10 Coexisting morbidities
open this folder and view contents8. Treatment of severe falciparum malaria14
open this folder and view contents9. Treatment of malaria caused by P. vivax, P. ovale or P. malariae19
View the document10. Mixed malaria infections
open this folder and view contents11. Complex emergencies and epidemics
open this folder and view contentsAnnexes

7.10 Coexisting morbidities

7.10.1 HIV infection13

13 Further information on malaria treatment and HIV/AIDS is provided in Annex 8.

Increasing numbers of people in malaria endemic areas are living with HIV infection. It is becoming increasingly apparent that, as HIV progresses and immunosuppression worsens, the manifestations of malaria also worsen. In pregnant women, the adverse effects on birth weight are increased. In patients with partial immunity to malaria, the severity of the infection is increased. There is insufficient information at the present time on how HIV infection modifies the therapeutic response to antimalarials. However, increasing parasite burdens and reduced host immunity, both of which occur with HIV infection, are associated with increased treatment failure rates. At this time, there is insufficient information to modify the general malaria treatment recommendations for patients with HIV/AIDS. Current UNAIDS/WHO recommendations on the prophylaxis of opportunistic infections with cotrimoxazole (trimethoprim-sulfamethoxazole) in people living with HIV/AIDS remain unchanged (see below). However, treatment with sulfadoxine-pyrimethamine should not be given to patients on cotrimoxazole as there is probably an increased risk of sulfa-related adverse effects (and in any case as both medicines have similar antimalarial activity, the malaria infection is likely to be resistant to sulfadoxine-pyrimethamine). Depending on the malaria transmission setting, HIV-infected individuals are at increased risk of asymptomatic parasitaemia, clinical malaria or severe and complicated malaria. Therefore, they have an even greater need for malaria control measures than individuals not infected with HIV.

EVIDENCE: treatment of malaria in patients co-infected with HIV

Interventions: oral ACTs, oral SP

Summary of RCTs: none.

Expert comment: observational studies suggest that malaria is more severe in patients co-infected with HIV. There is concern that severe adverse reactions to sulfonamides may be more frequent in HIV patients receiving cotrimoxazole (trimethoprim-sulfamethoxazole) for prophylaxis against opportunistic infections who are treated with SP for malaria.

Basis of decision: expert opinion.

Recommendation: there is insufficient evidence to recommend modifications to antimalarial treatment regimens in patients infected with HIV.

SP should be avoided for malaria treatment in HIV-infected patients receiving cotrimoxazole prophylaxis.

Summary of the recommendations on treatment of uncomplicated falciparum malaria in patients with HIV infection



Patients with HIV infection who develop malaria should receive standard antimalarial treatment regimens as recommended in the relevant sections of the guidelines.


Treatment or intermittent preventive treatment with sulfadoxine-pyrimethamine should not be given to HIV-infected patients receiving cotrimoxazole (trimethoprim-sulfamethoxazole) prophylaxis.


7.10.2 Severe malnutrition

Malaria and malnutrition frequently coexist. There are only a few studies of antimalarial medicine disposition in people with malnutrition, although many antimalarial drug efficacy studies have been conducted in populations and settings where malnutrition was prevalent (see Annex 3, section A3.17.2).

Changes in drug kinetics in malnutrition

Drug absorption may be reduced owing to diarrhoea and vomiting, rapid gut transit and atrophy of the bowel mucosa. Absorption of intramuscular and possibly intrarectal drugs may be slower and diminished muscle mass may make it difficult to administer repeated intramuscular injections. The volume of distribution of some drugs would be expected to be larger and plasma concentrations lower. Hypoalbuminaemia, resulting from decreased synthesis as dietary deficiency occurs, could lead to an increase in the concentration of unbound drug; this may increase metabolic clearance, but hepatic dysfunction may reduce the metabolism of some drugs.

Antimalarial drugs and protein energy malnutrition

There are limited studies of the effect of malnutrition on chloroquine, doxycycline, quinine, sulfadoxine-pyrimethamine and tetracycline, and not all of these studies were conducted in patients with malaria. There is insufficient evidence to suggest that the dosages in mg/kg bw of any antimalarial should be changed in patients with malnutrition.

There are no studies in malnourished patients of amodiaquine, artemisinin derivatives, artemether-lumefantrine, atovaquone-proguanil, clindamycin, mefloquine or primaquine.

Summary of the recommendations on treatment of uncomplicated falciparum malaria in malnourished patients



Although there are many reasons why drug kinetics may be different in malnourished patients as compared with those who are well nourished, there is insufficient evidence to change current mg/kg bw dosing recommendations.



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