Elsevier

Acta Tropica

Volume 124, Issue 3, December 2012, Pages 179-184
Acta Tropica

Malaria and helminthic co-infection among HIV-positive pregnant women: Prevalence and effects of antiretroviral therapy

https://doi.org/10.1016/j.actatropica.2012.08.004Get rights and content

Abstract

The impact of malaria on anemia and the interplay with helminths underline the importance of addressing the interactions between HIV/AIDS, malaria and intestinal helminth infections in pregnancy. The aim of this study was to determine the prevalence of malaria–helminth dual infections among HIV positive pregnant mothers after 12 months of ART. A cross sectional study was conducted on intestinal helminths and malaria dual infections among HIV-positive pregnant women attending antenatal health centers in Rwanda. Stool and malaria blood slide examinations were performed on 328 women residing in rural (n = 166) and peri-urban locations (n = 162). BMI, CD4 cell count, hemoglobin levels, type of ART and viral load of participants were assessed. Within the study group, 38% of individuals harbored helminths, 21% had malaria and 10% were infected with both. The most prevalent helminth species were Ascaris lumbricoides (20.7%), followed by Trichuris trichiura (9.2%), and Ancylostoma duodenale and Necator americanus (1.2%). Helminth infections were characterized by low hemoglobin and CD4 counts. Subjects treated with a d4T, 3TC, NVP regimen had a reduced risk of T. trichiura infection (OR, 0.27; 95% CIs, 0.10–0.76; p < 0.05) and malaria–helminth dual infection (OR, 0.29; 95% CI, 0.11–0.75; p < 0.05) compared to those receiving AZT, 3TC, NVP. This study shows a high prevalence of malaria and helminth infection among HIV-positive pregnant women in Rwanda. The differential effect of ARTs on the risk of helminth infection is of interest and should be examined prospectively in larger patient groups.

Graphical abstract

Helminth and malaria co-infection was higher in HIV-positive pregnant Rwandans in rural than in peri-urban areas. d4T–3TC–NVP regimen reduced the risk of helminth infection compared with AZT–3TC–NVP.

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Highlights

► Prevalence of helminth, malaria and dual-infection was 38%, 21%, and 10%, respectively. ► Helminth infection was characterized by lower hemoglobin and CD4 cell counts. ► Helminth infection was more common in rural than peri-urban areas. ► Helminth caused greater prevalence of detectable viral load than no infection. ► d4T–3TC–NVP therapy caused fewer helminth and dual infection than AZT–3TC–NVP.

Introduction

Helminth and malaria infections have been hypothesized to be factors likely to be driving the HIV-1 epidemic in Africa (Harms and Feldmeier, 2002, Slutsker and Marston, 2007). Globally, there are more than 2 billion people that are estimated to be infected with soil-transmitted helminths, with the geographical distribution of these infections overlapping considerably with regions of high HIV-1 sero-prevalence and malaria endemicity (Fincham et al., 2003, Hotez and Kamath, 2009). Malaria and helminth infections play a role in the pathogenesis of HIV-1 infection in Africa, due to their profound effects on the host immune system, which makes those infected more susceptible to HIV-1 infection (Harms and Feldmeier, 2002, Korenromp et al., 2005).

The combination of HIV, helminthic and plasmodial infection in the host creates an immunologically complex profile (Gallagher et al., 2005) and substantially increases the risk of anemia, which is caused by all three types of infections (Laufer et al., 2006). Therefore, in terms of co-infection with these diseases, pregnant women in sub-Saharan Africa represent a highly vulnerable group, particularly in light of data showing that helminth infection increases the risk of mother-to-child transmission of HIV (Gallagher et al., 2005).

Recent data on the prevalence of helminth infection in Rwanda for school-going children from eight districts indicated a prevalence of 64.5%. The observed prevalence was higher in rural than in urban settings (Mupfasoni et al., 2009). However, no studies have documented the prevalence of malaria and intestinal helminth dual infections among pregnant women with HIV/AIDS attending antenatal services in the setup of ARV roll-out programs. Therefore, the aim of this study was to determine the baseline prevalence of helminth and malaria dual infections in HIV-1 infected pregnant women attending Rwandan health centers after ART initiation.

Section snippets

Study area and population

Participants were enrolled among women attending the antenatal health center clinics in the provinces of Ruhuha, Mareba and Biryogo. After having given written informed consent, women in the second and third trimester of pregnancy were enrolled into the study. Women were excluded if they were HIV negative, below 18 years of age, had clinical evidence of TB, and had a treatment history of antihelminthic therapy and clinical confirmation of an abnormal pregnancy. On enrolment, subjects were

Participants’ characteristics

The study cohort of 328 pregnant women included 166 from rural and 162 from peri-urban centers. The median [interquartile range] age of the cohort was 27.0 [8] years with no significant difference in age between the 2 population groups. The mean BMI (±SD) of the total cohort was 25.4 ± 3.44 with women from the peri-urban (26.7 ± 2.88) group being significantly heavier than the rural (24.1 ± 3.46; p < 0.0001) population. Study participants were recruited to the study in the second and third trimesters

Discussion

The current study shows that helminth and malaria infection levels in HIV-positive pregnant women are high and that malaria and malaria–helminth dual infection are more common in rural than urban areas. Malaria–helminth dual infection was found to be a risk factor for reduced BMI, whilst helminth infection either on its own or in conjunction with malaria was found to lead to lower hemoglobin and CD4 levels. The ARV regimen of d4T, 3TC and NVP was found to significantly reduce the risk of T.

Disclosure

None of the authors has any conflict of interest to declare.

Role of the funding source

This study received financial assistance from the Government of Rwanda through the Ministry of Education Student Financing Agency of Rwanda [SFAR] and supplementary funding from the World Health Organization Special Programme for Training and Research on Tropical Diseases. None of the funding sources was involved in study design, collection, analysis and interpretation of the data, in the writing of the paper or in the decision to submit the paper for publication.

Acknowledgments

We acknowledge all participants for their valuable time and commitment to participate in the study, and we thank the staff of the health centers where the study was carried for their help with patient enrolment and appointments. We particularly acknowledge all the research staff for their contribution to this study.

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