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Effects of trimethoprim-sulfamethoxazole and insecticide-treated bednets on malaria among HIV-infected Ugandan children

Kamya, Moses Ra; Gasasira, Anne Fa; Achan, Janea; Mebrahtu, Tsedalb; Ruel, Theodoreb; Kekitiinwa, Adeodatac; Charlebois, Edwin Db; Rosenthal, Philip Jb; Havlir, Dianeb; Dorsey, Grantb

doi: 10.1097/QAD.0b013e3282ef6da1
Clinical Science

Background: Trimethoprim–sulfamethoxazole (TMP/SMX) prophylaxis and insecticide-treated bednets reduce malaria risk among HIV-infected adults. The efficacy of TMP/SMX may be diminished where antifolate resistance to malaria is high. We evaluated the efficacy of these interventions for malaria prevention among Ugandan children.

Methods: We concurrently followed 300 HIV-infected children aged 1–10 years and a community-based cohort of 561 healthy children aged 1–11 years over 11 months in Kampala, Uganda. The HIV-infected children received TMP/SMX prophylaxis and insecticide treated bednets. In the community cohort, insecticide-treated bednets were introduced during the observation period. Children from both cohorts were followed using a standardized protocol to measure the incidence of malaria.

Results: Only nine episodes of malaria were diagnosed among HIV-infected children (incidence = 0.07/person-year) in comparison with 440 episodes among children from the community (incidence = 0.90/person-year; P < 0.0001). The use of insecticide-treated bednets was associated with a 43% reduction in malaria incidence (P < 0.001), and a combination of TMP/SMX and use of insecticide-treated bednets with a 97% reduction in malaria incidence (P < 0.001). The prevalence of five mutations associated with antifolate resistance was high among malaria cases detected in both the HIV (100%) and community cohorts (75%). Malaria accounted for only 4% of febrile episodes in the HIV cohort in comparison with 33% in the community-based cohort (P < 0.0001).

Conclusion: In a malaria endemic area with a high level of molecular markers of antifolate resistance, the combined use of TMP/SMX prophylaxis and insecticide-treated bednets was associated with a dramatic reduction in malaria incidence among HIV-infected children.

From the aMakerere University Medical School, Kampala, Uganda

bDepartment of Medicine, San Francisco General Hospital, University of California, San Francisco, California, USA

cPaediatric Infectious Diseases Clinic, Mulago Hospital, Kampala, Uganda.

Received 3 April, 2007

Revised 30 May, 2007

Accepted 27 June, 2007

Correspondence to Moses R. Kamya, MBChB, MMed, MPH, Department of Medicine, Makerere University, P.O. Box 7072, Kampala, Uganda. E-mail:

© 2007 Lippincott Williams & Wilkins, Inc.