Helminthic infections rates and malaria in HIV-infected pregnant women on anti-retroviral therapy in Rwanda

Potential Interactions Between Soil-Transmitted Helminths and Herpes Simplex Virus Type II: Implications for Sexual and Reproductive Health in Sub-Saharan African

Sub-Saharan Africa (SSA) bears a disproportionate and overlapping burden of soil-transmitted helminths (STHs) and sexually transmitted viral infections. An estimated 232 million pre-school and school-aged children in SSA are vulnerable to STH infections. Together with this, SSA has a high prevalence of herpes simplex virus type II (HSV-2), the primary cause of genital herpes. Studies have examined the immunological interactions between STHs and human immunodeficiency virus and human papillomavirus during co-infections. However, epidemiological and immunological studies on STH-HSV-2 co-infections are lacking, therefore their impact on sexual and reproductive health is not fully understood. STH-driven Th2 immune responses are known to downregulate Th1/Th17 immune responses. Therefore, during STH-HSV-2 co-infections, STH-driven immune responses may alter host immunity to HSV-2 and HSV-2 pathology. Herein, we provide an overview of the burden of STH and HSV-2 infections in SSA, and host immune responses to STH and HSV-2 infections. Further, we emphasize the relevance and urgent need for (i) focused research into the interactions between these important pathogens, and (ii) integrated approaches to improve the clinical detection and management of STH-HSV-2 co-infections in SSA.

Herpes simplex virus type 2 in sub-Saharan Africa and the potential impact of helminth immune modulation

Herpes simplex virus type 2 (HSV-2) and helminth infections are among the most widespread infectious diseases in sub-Saharan Africa (SSA). Helminths are known to modulate host immune responses and consequently impact the severity and outcomes of unrelated diseases, including allergies, autoimmune conditions, and infectious diseases. In this way, helminths may modulate essential immune responses against HSV-2 during co-infection and may alter susceptibility to and pathology of HSV-2. However, the epidemiology of STH/HSV-2 co-infections is understudied, and whether helminths influence the host immune response to HSV-2 is not well understood. In this perspective piece, we briefly examine the current knowledge on helminth immune modulation of important pathogens that are endemic to SSA, arguing that it is important to explore HSV-2 and helminth co-infections to elucidate potential interactions between HSV-2 and helminths. This is particularly relevant in SSA, where both pathogens are highly prevalent.

Exploration of iron deficiency anemia and its associated factors among pregnant women seeking antenatal care in public health facilities of southwestern Ethiopia. A mixed study

BACKGROUND

Anemia is a major problem in Ethiopia, affecting a large part of the population. Despite the importance of the problem, the causes of anemia, especially iron deficiency anemia, among pregnant women attending antenatal care (ANC) in the study area have been little studied. Therefore, the aim of this study was to investigate iron deficiency anemia and its associated factors in pregnant women seeking antenatal care in public health facilities in Southwest Ethiopia in 2023.

METHODS AND MATERIALS

A mixed facility-based cross-sectional study was conducted involving 364 pregnant women from selected health facilities in Ilubabor and Buno Bedele zones. Backward multiple logistic regression was used to analyze the relationship between dependent and independent variables, with statistical significance set at a P value less than .05.

RESULTS

In this study, the prevalence of iron deficiency anemia was found to be 21.4%. Several factors have been significantly associated with iron deficiency anemia including; presence of malaria parasite [AOR=15.8, CI=5.1-48.4], presence of Helminthes [AOR=8.1, CI=2.8-23.9], consumption of leafy vegetables less than once a day [AOR=3.4, CI = 1.5-13.3] and not taking iron supplements/consumption [AOR=2.2, CI=1.1-4.4].

CONCLUSION AND RECOMMENDATIONS

The overall prevalence of iron deficiency anemia in the study area suggests that, it is a moderate public health problem. In order to improve the nutritional status of women, routine and consistent nutritional advice, the establishment of regular preventive systems and the implementation of feedback mechanisms are recommended.

Uncovering HIV and malaria interactions: the latest evidence and knowledge gaps

The geographical distribution of malaria and HIV infections widely overlap in sub-Saharan Africa, constituting a complex global health challenge. The interplay between both infections raises concerns about potential immunological, clinical, and therapeutic interactions. Both diseases have been reported to exacerbate the transmission of the other, including the possible vertical transmission of HIV in pregnant individuals with malaria. Co-infection also increases the risk of adverse outcomes such as severe malaria and death. In addition, interactions between antiretroviral and antimalarial drugs have been reported, potentially reducing the efficacy of these drugs. We review the current knowledge of the epidemiological, clinical, immunological, and therapeutic interactions of both infections. We focus on the latest available data and identify key knowledge gaps that should be addressed to guide policy makers in providing optimal HIV and malaria prevention, care, and treatment in vulnerable populations.

Burden of intestinal parasitic infections and associated factors among pregnant women in East Africa: a systematic review and meta-analysis

BACKGROUND

The ultimate goal of preventing intestinal parasites among pregnant women is to reduce maternal and newborn morbidity and mortality. Numerous primary studies were conducted in East Africa presented intestinal parasite infection and associated factors among pregnant women. However, the pooled finding is not known. Therefore, this review aimed to identify the pooled prevalence of intestinal parasite infection and its determinants among pregnant women in East Africa.

METHODS

Articles published from 2009 to 2021 were searched in PubMed, Web of Science, EMBASE, and HINARI databases. The search for unpublished studies such as thesis and dissertations was checked in Addis Ababa University and Africa Digital Library. PRISMA checklist was used to report the review. Articles published in the English Language were considered. The data were extracted by two authors using data extraction checklists on Microsoft excel. Heterogeneity among the included studies was checked using I² statistics on forest plots. Sensitivity and sub-group analyses were conducted to assess the presence of primary studies, and study characteristics responsible for the observed heterogeneity.

RESULTS

Of the 43 identified articles, about 23 articles were removed due to duplications. Then, by assessing the abstracts and full texts, four articles were removed because they failed to meet the eligibility criteria. Finally, 16 articles were included in the systematic and meta-analysis.The pooled prevalence of intestinal parasites among pregnant women in East Africa was 38.54 (28.77, 48.32). In this study, variables like residing in rural areas (OR: 3.75; CI: 1.15,12.16), availability of latrine(OR: 2.94; 95% CI: 2.22, 3.91), eating raw fruits/vegetables (OR: 2.44; 95% CI: 1.16, 5.11). and sources of water as unprotected sources (OR: 2.20; 95% CI: 1.11,4.35) show statistically significant association with the increased burden of intestinal parasites among pregnant women.

CONCLUSION

The burden of intestinal parasite infection among pregnant women in East Africa was high. Therefore, efforts should be made in deworming pregnant women at the community and institutional level by stakeholders to reduce the burden of intestinal parasite infections and related complications.

Malaria prevalence in HIV-positive children, pregnant women, and adults: a systematic review and meta-analysis

Background

Malaria in human immunodeficiency virus (HIV)-positive patients is an ever-increasing global burden for human health. The present meta-analysis summarizes published literature on the prevalence of malaria infection in HIV-positive children, pregnant women and adults.

Methods

This study followed the PRISMA guideline. The PubMed, Science Direct, Google Scholar, Scopus and Cochrane databases were searched for relevant entries published between 1 January 1983 and 1 March 2020. All peer-reviewed original papers evaluating the prevalence of malaria among HIV-positive patients were included. Incoherence and heterogeneity between studies were quantified by the I2 index and Cochran’s Q test. Publication and population biases were assessed with funnel plots, and Egger’s regression asymmetry test.

Results

A total of 106 studies were included in this systematic review. The average prevalence of malaria among HIV-positive children, HIV-positive pregnant women and HIV-positive adults was 39.4% (95% confidence interval [CI]: 26.6–52.9), 32.3% (95% CI = 26.3–38.6) and 27.3% (95% CI = 20.1–35.1), respectively. In adult patients with HIV, CD4+ (cluster of differentiation 4) < 200 cells/µl and age < 40 years were associated with a significant increase in the odds of malaria infection (odds ratio [OR] = 1.5, 95% CI = 1.2–1.7 and OR = 1.1, 95% CI = 1–1.3, respectively). Antiretroviral therapy (ART) and being male were associated with a significant decrease in the chance of malaria infection in HIV-positive adults (OR = 0.8, 95% CI = 0.7–0.9 and OR = 0.2, 95% CI = 0.2–0.3, respectively). In pregnant women with HIV, CD4+ count < 200 cells/µl was related to a higher risk for malaria infection (OR = 1.5, 95% CI = 1.1–1.9).

Conclusions

This systematic review demonstrates that malaria infection is concerningly common among HIV-positive children, pregnant women and adults. Among HIV-positive adults, ART medication and being male were associated with a substantial decrease in infection with malaria. For pregnant women, CD4+ count of < 200 cells/µl was a considerable risk factor for malaria infection.

Graphical Abstract

Equal contributions of feline immunodeficiency virus and coinfections to morbidity in African lions

Feline immunodeficiency virus (FIV) is a pathogenic lentivirus related to human and simian immunodeficiency viruses that has been associated with AIDS-like pathologies in domestic and wild cats, as well as in hyenas. Despite known pathologies, progressive immunosuppression and ill health effects driven by these lentiviruses in association with other secondary infections remain understudied in free-ranging species. Here, the role of coinfections by gastrointestinal parasites and tick-borne hemoparasites for FIV disease progression was explored in 195 free-ranging African lions (Panthera leo) living in Kruger National Park (KNP), South Africa. Using statistical methodology, we evaluated the effects of FIV on a range of health indicators to explore how direct and indirect effects of FIV and associated coinfections align to determine lion health outcomes. Findings show direct negative effects of FIV on host immunity and nutritional status, and exacerbation of aggressive behaviors, conditions which may increase exposure/susceptibility to other secondary infections. When taken together, the contribution of coinfecting parasites to morbidity in lions is of similar magnitude as direct effects of FIV infection alone, suggesting that the particular coinfection assemblage may play a role in mediating disease progression within natural lion populations.

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Immunosuppression by FIV increases richness and abundance of secondary parasites.

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Infection by gastrointestinal parasites drives severe malnourishment in FIV hosts.

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Hemoparasite infection contributed to liver pathology and clinical wasting.

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Contributions of secondary infections to morbidity equal the direct effects of FIV.

Canine Gastrointestinal Nematodiases and Associated Risk Factors in Kigali City, Rwanda

Canine nematodes pose a public health risk to humans and livestock; however, the prevalence of canine nematodiases in Rwanda is unknown. This study aimed at determining the prevalence of canine nematodiases and identifying the risk factors for such infections in Kigali, the capital city of Rwanda. A cross-sectional study involved 93 dogs selected across Kigali city. Faecal samples were collected from apparently healthy dogs, and nematode eggs were identified and quantified using the McMaster technique. Risk factors for canine nematodiases were analysed by a multivariable binary logistic regression model. The overall prevalence of gastrointestinal (GI) nematodiases in dogs was 33.3% (95% CI: 23.8-42.9). The most prevalent species was Ancylostoma spp with 32.3% (95% CI: 22.8-41.8). Nearly 38.7% and 3.2% of the dogs infected with Ancylostoma spp and Toxocara canis had high egg counts per gram (EPG) of faeces (≥550), respectively. Approximately 96.8% of dogs infected with nematodes had monoinfection. Logistic regression analysis showed that dog's age (1 to 2.5 years old), location (Gasabo and Kicukiro districts), and feeding practices were significantly associated with prevalence of canine nematodiases. In particular, the adjusted odds ratio (AOR) was more than 5 times higher for dogs fed on uncooked animal products and leftovers from households and restaurants compared to those who ate food prepared for them. The AOR was also about 16 times higher for dogs that scavenged and ate leftovers from households compared to those who ate food prepared for them. The findings of this study indicate that the prevalence of GI nematodes in domestic dogs in Kigali city, Rwanda, was 33.3% (95% CI: 23.8-42.9). The identified nematodes, namely, Ancylostoma spp. and Toxocara canis, are zoonotic, and dogs and humans are at risk of contracting these nematodes. The factors associated with canine GI nematodes in Kigali city include feeding practices and the dog's age and location (district). Dog owners need to rethink procedures for deworming and feeding their dogs. Again, the public should be made aware of the role of dogs in transmitting zoonotic nematodes to humans.

Global prevalence of intestinal parasitic infections and associated risk factors in pregnant women: a systematic review and meta-analysis

BACKGROUND

Intestinal parasitic infections (IPIs) during pregnancy, if left untreated, can cause adverse effects for the mothers, foetuses and newborns. However, limited information is available about the global status of IPIs in pregnant women. Here we undertook a meta-analysis to estimate the global prevalence of IPIs and associated risk factors in pregnant women.

METHODS

We searched the PubMed, Science Direct, Scopus, Web of Science and Google Scholar databases for relevant studies that were published between 1 January 1987 and 30 December 2019. A random effects meta-analysis model was used to estimate the pooled prevalence, odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

A total of 114 studies comprising 98 342 pregnant women across 35 countries were included in the systematic review and meta-analysis. Among IPIs identified from pregnant women, three helminth infections (hookworm 19% [95% CI 15 to 23], Ascaris lumbricoides 17% [95% CI 13 to 21] and Trichuris trichiura 11% [95% CI 7 to 16]) and three protozoan infections (Blastocystis sp. 21% [95% CI 4 to 46], Entamoeba histolytica/dispar 9% [95% CI 3 to 19] and Giardia sp. 8% [95% CI 4 to 13]) were identified as the most prevalent intestinal parasites. Moreover, we found that there was a significant association between IPIs with increased risk of anaemia in pregnant women (OR 2.65 [95% CI 2.08 to 3.37]). The prevalence of IPIs was slightly higher in geophagic pregnant women compared with controls, but this was not significant (OR 1.22 [95% CI 0.87 to 1.71]). According to species, the pooled OR of A. lumbricoides infection had a significantly higher risk in geophagic pregnant women compared with controls (OR 2.66 [95% CI 1.37 to 5.16]). There was a positive relationship between the high prevalence of IPIs in pregnant women living in rural areas compared with urban residents (OR 3.36 [95% CI 1.57 to 7.19]).

CONCLUSIONS

The current review revealed a relatively high prevalence of IPIs in pregnant women, especially in some low- and middle-income countries. These results suggest a need for improved prevention and control efforts to reduce the health risks to pregnant women.

Epidemiology of malaria among HIV/AIDS patients in sub-Saharan Africa: A systematic review and meta-analysis of observational studies

Malaria related HIV morbidity and death is a concern in sub-Saharan Africa. Understanding the epidemiology of malaria among people living with HIV is vital for adequate intervention. We conducted a systematic review and meta-analysis to estimate the prevalence of malaria in HIV patients in sub-Saharan Africa. We searched PubMed, AJOL, Web of Science and Google Scholar databases. The overall pooled prevalence and pooled Odds Ratio (OR) with their 95% Confidence Intervals (CI) were estimated using the random-effects model and potential causes of heterogeneity in prevalence estimates were investigated using subgroup and meta-regression analysis. 58 studies, including 23,911 HIV patients, were identified between January 1990 and October 2020. The overall pooled prevalence of malaria in HIV patients was 22.7% (95% CI 18.0; 28.1). The Prevalence of malaria among HIV/AIDS patients was 33.1%, 30.2%, 15.3%, and 12.6% in Southern, Western, Central, and Eastern regions of SSA respectively. Prevalence of malaria in the central and western was higher [26.7% (95% CI 20.6; 33.9)] than 13.6% reported in the southern and eastern regions (95% CI 8.8; 20.5). There was a significant decrease in malaria prevalence among HIV/AIDS patients in the Eastern and Southern SSA regions from 21.9% (95% CI 15.5; 30.0) in the 2000-2010 period to 9.7% (95% CI 5.5-16.4) in the post-2010 period compared to the central and western regions. HIV infected patients with low CD4 + T cell count (CD4 < 200 cells/mm3) were 2.19 times more likely to become infected with malaria than those with high CD4 + T cell count (CD4 ≥ 200 cells/mm3) (pooled odds ratio (POR): 2.19 (95%CI 1.20;3.98), while patients on antiretroviral therapy (POR): 0.37 (0.23; 0.59), and in WHO clinical stages I and II (POR): 0.64 (0.28; 1.46), had a lower odds of been infected with malaria. Our review suggests that due consideration should be given to malaria among HIV/AIDS patients in SSA. In particular, the assessment and improvement of preventive measures for malaria/HIV co-infection in high-prevalence regions is important. For the treatment of both diseases, prophylaxis with cotrimoxazole and antiretroviral therapy should also be encouraged.

Malaria, Helminth Infections and Clinical Status Among HIV-Infected Pregnant Women

BACKGROUND OR OBJECTIVES

Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) is widespread in sub-Saharan Africa with similarity in geographical distribution of major pathogens of public health interest. The aim of this study was to assess the effect of malaria and helminths on CD4 count, hematocrit values and viral load among HIV-infected pregnant women.

METHODS

One hundred and ninety-seven HIV-infected pregnant women aged 18-45 years were recruited from a registered HIV clinic and questionnaires were administered for socio-demographic details. Screening for malaria parasites in blood was through microscopy while helminths were identified in stool using Kato-Katz method. Hematocrit levels were determined through centrifugation of blood collected in capillary tubes. At the time of recruitment, most recent CD4 count and viral load was obtained from the patients' case notes.

RESULTS

About three-quarters (73.6%) of the women had above primary school level of education while more than half (60.2%) were petty traders. The prevalence of malaria parasites in the blood samples was 24.9%, while 3% were infected with helminths. There was only a single case of malaria, helminths and HIV co-infection in the study group. Prevalence of anemia was 75.6% with eight cases (4.1%) of severe anemia. About 86.6% of the women with anemia had low CD4 count (χ²= 8.801, p=0.032). The mean CD4 count was significantly lower among those with co-infection of malaria and HIV.

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

Malaria or helminth infection among HIV-infected women lowers the CD4 count and increases the viral load with little changes in hematocrit values. Routine screening of HIV-infected women for probable multiple infections will aid in improving their overall health and well-being.

Associations of malaria, HIV, and coinfection, with anemia in pregnancy in sub-Saharan Africa: a population-based cross-sectional study

BACKGROUND

Malaria and HIV are common infections in Africa and cause substantial morbidity and mortality in pregnant women. We aimed to assess the association of malaria with anemia in pregnant women and to explore the joint effects of malaria and HIV infection on anemia in pregnant women.

METHODS

We used nationally representative, cross-sectional demographic and health surveys (DHS) that were conducted between 2012 and 2017 across 7 countries of sub-Saharan Africa (Burundi, the Democratic Republic of the Congo, Gambia, Ghana, Mali, Senegal and Togo). The outcome variables were anemia (defined as a hemoglobin concentration < 110 g/L), and hemoglobin concentration on a continuous scale, in pregnant women at the time of the interview. We used generalized linear mixed-effects models to account for the nested structure of the data. We adjusted models for individual covariates, with random effects of the primary sampling unit nested within a country.

RESULTS

A total of 947 pregnant women, ages, 15-49 y, were analyzed. Prevalence of malaria only, HIV only, and malaria- HIV coinfection in pregnant women was 31% (95% CI: 28.5 to 34.5%, n = 293), 1.3% (95% CI: 0.77 to 2.4%, n = 13) and 0.52% (95% CI: 0.02 to 1.3%, n = 5) respectively. Overall prevalence of anemia was 48.3% (95% CI: 45.1 to 51.5%). The anemia prevalence in pregnant women with malaria infection only was 56.0% (95% CI: 50.1 to 61.7%); HIV infection only, 62.5% (95% CI: 25.9 to 89.8%); malaria- HIV coinfection, 60.0 (95% CI: 17.0-92.7%) and without either infection, 44.6% (95% CI: 40.7 to 48.6%). In the fully adjusted models, malaria infection was associated with 27% higher prevalence of anemia (95% CI of prevalence ratio: 1.12 to 1.45; p = 0.004), and 3.4 g/L lower hemoglobin concentration (95% CI: - 5.01 to - 1.79; p = 0.03) compared to uninfected pregnant women. The prevalence of HIV infection and malaria-HIV coinfection was too low to allow meaningful analysis of their association with anemia or hemoglobin concentration.

CONCLUSION

Malaria was associated with an increased prevalence of anemia during pregnancy.

The Consequences of Mixed-Species Malaria Parasite Co-Infections in Mice and Mosquitoes for Disease Severity, Parasite Fitness, and Transmission Success

The distributions of human malaria parasite species overlap in most malarious regions of the world, and co-infections involving two or more malaria parasite species are common. Little is known about the consequences of interactions between species during co-infection for disease severity and parasite transmission success. Anti-malarial interventions can have disproportionate effects on malaria parasite species and may locally differentially reduce the number of species in circulation. Thus, it is important to have a clearer understanding of how the interactions between species affect disease and transmission dynamics. Controlled competition experiments using human malaria parasites are impossible, and thus we assessed the consequences of mixed-species infections on parasite fitness, disease severity, and transmission success using the rodent malaria parasite species Plasmodium chabaudi, Plasmodium yoelii, and Plasmodium vinckei. We compared the fitness of individual species within single species and co-infections in mice. We also assessed the disease severity of single vs. mixed infections in mice by measuring mortality rates, anemia, and weight loss. Finally, we compared the transmission success of parasites in single or mixed species infections by quantifying oocyst development in Anopheles stephensi mosquitoes. We found that co-infections of P. yoelii with either P. vinckei or P. chabaudi led to a dramatic increase in infection virulence, with 100% mortality observed in mixed species infections, compared to no mortality for P. yoelii and P. vinckei single infections, and 40% mortality for P. chabaudi single infections. The increased mortality in the mixed infections was associated with an inability to clear parasitaemia, with the non-P. yoelii parasite species persisting at higher parasite densities than in single infections. P. yoelii growth was suppressed in all mixed infections compared to single infections. Transmissibility of P. vinckei and P. chabaudi to mosquitoes was also reduced in the presence of P. yoelii in co-infections compared to single infections. The increased virulence of co-infections containing P. yoelii (reticulocyte restricted) and P. chabaudi or P. vinckei (predominantly normocyte restricted) may be due to parasite cell tropism and/or immune modulation of the host. We explain the reduction in transmission success of species in co-infections in terms of inter-species gamete incompatibility.

Effects of malaria/helminthic coinfections on cervical cancer progression among sub Saharan African women on highly active antiretroviral therapy: A scoping review

In Africa, the HIV prevalence in rural areas has begun to reach levels estimated within urban settings, where women are also more at risk for both malaria and intestinal parasitic infections. The objective of this review is to assess whether concomitant infections with malaria and/or helminthic diseases have an impact on cervical disease progression in women on HAART. This scoping review was conducted in August 2018. To conduct this scoping review, we searched the relevant studies in electronic databases such as PUBMED, Global Health, EMBASE, CINAHL and SCOPUS published in the year between 1960 and 2018 using the following search terms HAART AND malaria OR Helminth and Female OR women. Eight studies qualified for this review. The literature underscores the need for women on HAART with multiple co-infections to use adjuncts to retain immune recovery and undetectable HIV viral load, to reduce risk of cervical disease progression. A trend for higher risk of CIN3+ in HIV+ women reporting recent malarial infection was observed in one study. Given the public health impact of synergistic interactions between malaria and helminthic infections in HIV/HPV co-infected women on HAART, it is urgent that these interactions are elucidated.

Seroprevalence of Malaria and Hepatitis B Coinfection among Pregnant Women in Tamale Metropolis of Ghana: A Cross-Sectional Study

Background

Coinfections are becoming common risk factors that may contribute to the increased burden of morbidity in pregnancy. The aim of this study was to assess the seroprevalence of coinfections of malaria, hepatitis B (HBV), human immunodeficiency virus (HIV), and syphilis among pregnant women attending antenatal clinics (ANC) in the Tamale Metropolis.

Methods

By means of rapid diagnostic tests (RDTs), pregnant women attending the Tamale Teaching Hospital (TTH) were screened for malaria, HBV infection, HIV infection, and syphilis from March 2013 to February 2015. Haemoglobin (Hb) values, sickling, and glucose-6-phosphate dehydrogenase deficiency (G6PDd) statuses were also assessed using full blood count (FBC), sodium metabisulphite, and methaemoglobin reduction tests, respectively. Logistic regression analysis was performed to estimate the risks/odds ratios (ORs) for the coinfections and other variables (age, gravidity, and time of the first ANC visit) with 95% confidence intervals (CIs) and set p values for accepting any differences at <0.05.

Results

Within the two-year study period, data were collected from 3,127 pregnant women. The mean age (SD) of the pregnant women was 28.5 (±5.0) years. Of the total number, seroprevalence was high for malaria (11.6%) and HBV infection (4.2%) and low for HIV infection (1.0%) and syphilis (0.4%) monoinfections. Mal/HBV coinfection was higher (0.7%) when compared with Mal/HIV (0.1%), Mal/syphilis (0.0%), HBV/HIV (0.0%), HBV/syphilis (0.1%), and HIV/syphilis (0.0%) coinfections. The mean Hb (g/dl) for the women with the four monoinfections was significantly different from one another (p=0.009). Pregnant women with malaria infection were about 2 times more likely to be coinfected with HBV even after adjusting for potential confounders (adjusted odds ratio (AOR) = 1.66, 95% CI = 1.04-2.65, p=0.031). Those in their third trimester and visiting the ANC for the first time were significantly less likely to be infected with HBV (AOR = 0.45, 95% CI = 0.28-0.73, p=0.001), with malaria/HBV coinfection (AOR = 0.09, 95% CI = 0.01-0.68, p=0.020), and with any coinfection (AOR = 0.19, 95% CI = 0.06-0.63, p=0.007).

Conclusion

A comparatively high seroprevalence of malaria and its coinfection with HBV in pregnant women was observed in this study. Considering the effects that both malaria and HBV have on the liver, it would be expedient to conduct further studies to assess liver function among malaria/HBV-infected individuals, while interventions to prevent coinfections among pregnant women are intensified.

Prevalence and associated factors of Plasmodium falciparum and soil transmitted helminth infections among pregnant women in Osun state, Nigeria

BACKGROUND

Plasmodium falciparum and soil transmitted helminth (STHs) infection are widespread in sub-Sahara Africa, where co-infection is also common. This study assessed the prevalence of these infections and their risk factors among pregnant women in Osogbo, Nigeria.

METHODS

A total of 200 pregnant women attending the antenatal clinic were recruited. Plasmodium falciparum was detected using thick and thin film methods, while formol ether concentration method was used for STHs detection. A questionnaire was used to investigate the possible risk factors associated with acquisition of malaria and helminth infections.

RESULTS

The prevalence of P. falciparum, STHs and their co-infection was 29.5%, 12% and 5% respectively. P. falciparum, STHs and P. falciparum + STHs co-infection was significantly higher in primigravidae (52.5% vs 58.3% vs 80%) than in secongravidae (18.6% vs 25.0% vs 20%) and multigravidae (28.8% vs 16.7% vs 0%) (p=0.02). Prevalence associated factors identified for P. falciparum was age (p=0.0001) while gravidity (p=0.02) was identified for P. falciparum + STHs co-infection.

CONCLUSION

High prevalence of P. falciparum and helminth infections was observed among the pregnant women with primigravidae being the most susceptible to co-infection. There is an urgent need to implement an effective malaria and STHs preventive method for this high risk population.

Schistosoma haematobium effects on Plasmodium falciparum infection modified by soil-transmitted helminths in school-age children living in rural areas of Gabon

BACKGROUND

Malaria burden remains high in the sub-Saharan region where helminths are prevalent and where children are often infected with both types of parasites. Although the effect of helminths on malaria infection is evident, the impact of these co-infections is not clearly elucidated yet and the scarce findings are conflicting. In this study, we investigated the effect of schistosomiasis, considering soil-transmitted helminths (STH), on prevalence and incidence of Plasmodium falciparum infection.

METHODOLOGY

This longitudinal survey was conducted in school-age children living in two rural communities in the vicinity of Lambaréné, Gabon. Thick blood smear light microscopy, urine filtration and the Kato-Katz technique were performed to detect malaria parasites, S. haematobium eggs and, STH eggs, respectively. P. falciparum carriage was assessed at inclusion, and incidence of malaria and time to the first malaria event were recorded in correlation with Schistosoma carriage status. Stratified multivariate analysis using generalized linear model was used to assess the risk of plasmodium infection considering interaction with STH, and survival analysis to assess time to malaria.

MAIN FINDINGS

The overall prevalence on subject enrolment was 30%, 23% and 9% for S. haematobium, P. falciparum infections and co-infection with both parasites, respectively. Our results showed that schistosomiasis in children tends to increase the risk of plasmodium infection but a combined effect with Trichuris trichiura or hookworm infection clearly increase the risk (aOR = 3.9 [95%CI: 1.7-9.2]). The incidence of malaria over time was 0.51[95%CI: 0.45-0.57] per person-year and was higher in the Schistosoma-infected group compared to the non-infected group (0.61 vs 0.43, p = 0.02), with a significant delay of time-to first-malaria event only in children aged from 6 to 10-years-old infected with Schistosoma haematobium.

CONCLUSIONS

Our results suggest that STH enhance the risk for P. falciparum infection in schistosomiasis-positive children, and when infected, that schistosomiasis enhances susceptibility to developing malaria in young children but not in older children.

Malaria and HIV coinfection in sub-Saharan Africa: prevalence, impact, and treatment strategies

Malaria and HIV, two of the world's most deadly diseases, are widespread, but their distribution overlaps greatly in sub-Saharan Africa. Consequently, malaria and HIV coinfection (MHC) is common in the region. In this paper, pertinent publications on the prevalence, impact, and treatment strategies of MHC obtained by searching major electronic databases (PubMed, PubMed Central, Google Scholar, ScienceDirect, and Scopus) were reviewed, and it was found that the prevalence of MHC in SSA was 0.7%-47.5% overall. Prevalence was 0.7%-47.5% in nonpregnant adults, 1.2%-27.8% in children, and 0.94%-37% in pregnant women. MHC was associated with an increased frequency of clinical parasitemia and severe malaria, increased parasite and viral load, and impaired immunity to malaria in nonpregnant adults, children, and pregnant women, increased in placental malaria and related outcomes in pregnant women, and impaired antimalarial drug efficacy in nonpregnant adults and pregnant women. Although a few cases of adverse events have been reported in coinfected patients receiving antimalarial and antiretroviral drugs concurrently, available data are very limited and have not prompted major revision in treatment guidelines for both diseases. Artemisinin-based combination therapy and cotrimoxazole are currently the recommended drugs for treatment and prevention of malaria in HIV-infected children and adults. However, concurrent administration of cotrimoxazole and sulfadoxine-pyrimethamine in HIV-infected pregnant women is not recommended, because of high risk of sulfonamide toxicity. Further research is needed to enhance our understanding of the impact of malaria on HIV, drug-drug interactions in patients receiving antimalarials and antiretroviral drugs concomitantly, and the development of newer, safer, and more cost-effective drugs and vaccines to prevent malaria in HIV-infected pregnant women.

Anemia in people on second line antiretroviral treatment in Lilongwe, Malawi: a cross-sectional study

Background

Anemia is common among people living with HIV infection and is frequently associated with poor quality of life and poor prognosis. It has been well described in antiretroviral naïve individuals and those on non-nucleoside reverse transcriptase inhibitor-based first line antiretroviral therapy (ART) regimens. However there is limited information on anemia for ART experienced individuals on protease inhibitor-based second line ART regimens in resource limited settings. Our objective was to describe the prevalence and risk factors of anemia in this ART experienced population in Malawi.

Methods

We conducted a cross-sectional study using routine facility data at two HIV clinics in Lilongwe, Malawi. The analysis included individuals receiving protease inhibitor-based second line ART. Clinical and laboratory data were collected at routine clinic visits. We used descriptive statistics, two-sample t-tests and multivariate logistic regression for data analysis.

Results

Three hundred seventy-seven records were included in this analysis (37% male, median age 41 years, median CD4 count 415 cells/μL). The prevalence of anemia was 125/377 (33.2%) − mild, moderate and severe anemia was 17.5%, 13.8%, and 1.9% respectively. Female participants had a higher prevalence than male participants (43.6% vs. 15.7%, p < 0.001). In multivariate logistic regression, female sex (adjusted odds ratio (aOR) 5.3; 95% CI 2.9–9.5) and a CD4 count <200 cell/ul (aOR 3.1; 95%CI 1.6–6.0) were associated with increased risk of having anemia while a BMI ≥30 kg/m2 (aOR 0.8; 95% CI 0.6–1.0) and being on ART for more than 10 years (aOR 0.4; 95% CI 0.2–0.9) were associated with reduced risk of anemia. Being on a zidovudine- containing ART regimen was not associated with anemia.

Conclusion

Anemia is common in people on second line ART in Lilongwe, Malawi. Screening for anemia in this population would be a useful strategy; especially for female patients, those who are underweight and have a low CD4 cell counts.

Coinfection with Schistosoma haematobium and Plasmodium falciparum and Anaemia Severity among Pregnant Women in Munyenge, Mount Cameroon Area: A Cross-Sectional Study

Background. Malaria and urogenital schistosomiasis are coendemic in Mount Cameroon Area. This study investigated the prevalence of S. haematobium, P. falciparum, and coinfections and their effect on anaemia in pregnancy. Methods. Pregnant women reporting for antenatal care (ANC) clinic visit in Munyenge were enrolled. S. haematobium and P. falciparum infections were determined by urine filtration and microscopy, respectively. Haemoglobin (Hb) levels were measured using haemoglobinometer. Of 250 women, 46.8%, 39.2%, and 15.2% had S. haematobium, P. falciparum, and coinfections, respectively. Schistosomes infection was higher in younger women (≤25 years) and those who bathe in and had domestic contact with stream compared with older age (>25 years) women and those who had only domestic contact with stream. Lower infection rate was associated with less water contact (≤2 times/day) compared with more water contact (>2 times/day). Compared with no sulphadoxine-pyrimethamine (SP) usage, malaria parasitaemia was less among women who used SP. Stream usage increased risk of coinfection while less water contact and SP usage decreased its risk. All coinfected cases were anaemic and coinfection accounted for 93.8% of severe anaemia. Conclusion. Coinfection contributes to anaemia severity. Less water contact and SP usage will reduce coinfection in pregnancy in Munyenge.

Parasitic infections and maternal anaemia among expectant mothers in the Dangme East District of Ghana

BACKGROUND

Parasitic infections are of public health concern globally, particular among at risk groups such as pregnant women in developing countries. The presence of these parasites during pregnancy potentiate adverse effects to both the mother and the unborn baby. This study sought to establish the prevalence of some parasitic agents among antenatal attendees in the Dangme East District of Ghana. A cross-sectional prospective study was conduct between April and July, 2012. Venous blood specimens were collected from each participant for haemoglobin estimation and malaria microscopy. In addition participants' early morning mid-stream urine and stool specimens were analyzed microscopically for parasitic agents.

RESULTS

A total of 375 pregnant women were involved in the study, of which anaemia was present in 66.4% (249/375). However, parasitic infections associated anaemia prevalence was 49.6% (186/375). In all, 186 cases of parasitic infections were observed; 171 (44.0%) were single isolated infections while 15 (4.0%) were co-infections. Plasmodium species were significantly associated with anaemia (13.3%, χ² = 23.290, p < 0.001). Also, the presence of Schistosoma haematobium (3.7%, χ² = 7.267, p = 0.008), Schistosoma mansoni (5.3%, χ² = 5.414, p = 0.023) and hookworm (3.7%, χ² = 11.267, p = 0.008) were significantly associated with anaemia in pregnancy. Except where co-infections exist (3.7%, χ² = 11.267, p = 0.001), the rest of the single infections were insignificantly associated with anaemia. Collectively, intestinal helminthes were predominantly significant with anaemia in pregnancy (p = 0.001, χ² = 107.800).

CONCLUSION

The study revealed relatively high prevalence of parasitic infections among the study population, suggesting that about three-quarters of the anaemic mothers are either single or co-infected with parasitic agents.

Implementation of co-trimoxazole preventive therapy policy for malaria in HIV-infected pregnant women in the public health facilities in Tanzania

Background

In 2011, Tanzania adopted a policy for provision of daily co-trimoxazole prophylaxis to HIV-infected pregnant women for prevention of malaria and other opportunistic infections. As per the policy, HIV-infected pregnant women should not be given sulfadoxine-pyrimethamine (SP) for intermittent preventive therapy. The challenges associated with this policy change and the extent to which the new policy for prevention of malaria in pregnant women coinfected with HIV was implemented need to be assessed.

Aim

To assess the implementation of malaria-preventive therapy policy among HIV-infected pregnant women in the public health facilities in Dar es Salaam, Tanzania.

Methodology

The study was conducted in Kinondoni Municipality, Dar es Salaam, Tanzania, from January 2015 to July 2015. Three hundred and fifty-three HIV-infected pregnant women who were attending antenatal clinics (ANCs) and using co-trimoxazole for prevention of malaria were interviewed. Twenty-six health care workers working at the ANCs were also interviewed regarding provision of co-trimoxazole prophylaxis to pregnant women. A knowledge scale was used to grade the level of knowledge of health care providers. Focus group discussions were also conducted with 18 health care workers to assess the level of implementation of the policy and the challenges encountered.

Results

Twenty-three (6.5%) pregnant women with known HIV serostatus were using co-trimoxazole for prevention of opportunistic infections even before they became pregnant. Out of the 353 HIV-infected pregnant women, eight (2.5%) were coadministered with both SP and co-trimoxazole. Sixty (16.7%) pregnant women had poor adherence to co-trimoxazole prophylaxis. Out of the 26 interviewed health care providers, 20 had high level of knowledge regarding malaria-preventive therapy in HIV-infected pregnant women. Lack of adequate supply of co-trimoxazole in health facilities and inadequate training of health care providers were among the factors causing poor implementation of co-trimoxazole prophylaxis for prevention of malaria in HIV-infected pregnant women.

Conclusion

There is a need to continue sensitization of pregnant women and communities about the importance of early attendance to the ANCs for testing of HIV and provision of co-trimoxazole prophylaxis. Availability of co-trimoxazole in the health facilities, regular training, and sensitization of health care providers are necessary for effective implementation of this policy.

Filariae-Retrovirus Co-infection in Mice is Associated with Suppressed Virus-Specific IgG Immune Response and Higher Viral Loads

Worldwide more than 2 billion people are infected with helminths, predominantly in developing countries. Co-infections with viruses such as human immunodeficiency virus (HIV) are common due to the geographical overlap of these pathogens. Helminth and viral infections induce antagonistic cytokine responses in their hosts. Helminths shift the immune system to a type 2-dominated immune response, while viral infections skew the cytokine response towards a type 1 immune response. Moreover, chronic helminth infections are often associated with a generalized suppression of the immune system leading to prolonged parasite survival, and also to a reduced defence against unrelated pathogens. To test whether helminths affect the outcome of a viral infection we set up a filarial/retrovirus co-infection model in C57BL/6 mice. Although Friend virus (FV) infection altered the L. sigmodontis-specific immunoglobulin response towards a type I associated IgG2 isotype in co-infected mice, control of L. sigmodontis infection was not affected by a FV-superinfection. However, reciprocal control of FV infection was clearly impaired by concurrent L. sigmodontis infection. Spleen weight as an indicator of pathology and viral loads in spleen, lymph nodes (LN) and bone marrow (BM) were increased in L. sigmodontis/FV-co-infected mice compared to only FV-infected mice. Numbers of FV-specific CD8⁺ T cells as well as cytokine production by CD4⁺ and CD8⁺ cells were alike in co-infected and FV-infected mice. Increased viral loads in co-infected mice were associated with reduced titres of neutralising FV-specific IgG2b and IgG2c antibodies. In summary our findings suggest that helminth infection interfered with the control of retroviral infection by dampening the virus-specific neutralising antibody response.

The coincidental infection of a host with two different pathogens is widespread in low-income countries. Regions where helminth infections are endemic strongly overlap with areas where the incidence of viral infections such as HIV is high. HIV is a major public health issue causing more than 1 million deaths per year. To analyse the impact of a pre-existing helminth infection on a viral infection we established a helminth/retrovirus co-infection mouse model. Mice that were first infected with Litomosoides sigmodontis and subsequently with a murine retrovirus showed a more severe course of virus infection, i.e. exaggerated splenomegaly and higher viral loads. Since different lymphocytes such as B and T cells contribute to viral control we analysed the cellular and humoral immune response. While T cell responses were similar in co-infected and virus-infected mice, we observed reduced titres of virus-specific antibodies in co-infected mice. Our results suggest that helminth infection interfered with viral control by dampening the virus-specific antibody response. The viral infection itself altered the humoral immune response against L. sigmodontis without changing the worm burden. In summary, our data highlight the importance of deworming programs or vaccines against helminths in developing countries where the incidence of helminth/HIV co-infections is high.

Practical Management of HIV-Associated Anemia in Resource-Limited Settings: Prospective Observational Evaluation of a New Mozambican Guideline

Mozambique's updated guideline for management of HIV-associated anemia prompts clinicians to consider opportunistic conditions, adverse drug reactions, and untreated immunosuppression in addition to iron deficiency, intestinal helminthes, and malaria. We prospectively evaluated this guideline in rural Zambézia Province. Likely cause(s) of anemia were determined through prespecified history, physical examination, and laboratory testing. Diagnoses were "etiologic" if laboratory confirmed (sputum microscopy, blood culture, Plasmodium falciparum malaria rapid test) or "syndromic" if not. To assess hemoglobin response, we used serial point-of-care measurements. We studied 324 ambulatory, anemic (hemoglobin <10 g/dl) HIV-infected adults. Study clinicians treated nearly all [315 (97.2%)] for suspected iron deficiency and/or helminthes; 56 (17.3%) had laboratory-confirmed malaria. Other assigned diagnoses included tuberculosis [30 (9.3%)], adverse drug reactions [26 (8.0%)], and bacteremia [13 (4.1%)]. Etiologic diagnosis was achieved in 79 (24.4%). Of 169 (52.2%) subjects who improved (hemoglobin increase of ≥1 g/dl without indications for hospitalization), only 65 (38.5%) received conventional management (iron supplementation, deworming, and/or antimalarials) alone. Thirty (9.3%) died and/or were hospitalized, and 125 (38.6%) were lost to follow-up. Multivariable linear and logistic regression models described better hemoglobin responses and/or outcomes in subjects with higher CD4(+) T-lymphocyte counts, pre-enrollment antiretroviral therapy and/or co-trimoxazole prophylaxis, discontinuation of zidovudine for suspected adverse reaction, and smear-positive tuberculosis. Adverse outcomes were associated with fever, low body mass index, bacteremia, esophageal candidiasis, and low or missing CD4(+) T cell counts. In this severely resource-limited setting, successful anemia management often required interventions other than conventional presumptive treatment, thus supporting Mozambique's guideline revision.

Impact of Anti-Retroviral Treatment and Cotrimoxazole Prophylaxis on Helminth Infections in HIV-Infected Patients in Lambaréné, Gabon

Background

Foci of the HIV epidemic and helminthic infections largely overlap geographically. Treatment options for helminth infections are limited, and there is a paucity of drug-development research in this area. Limited evidence suggests that antiretroviral therapy (ART) reduces prevalence of helminth infections in HIV-infected individuals. We investigated whether ART exposure and cotrimoxazole preventive therapy (CTX-P) is associated with a reduced prevalence of helminth infections.

Methodology and Principal Findings

This cross-sectional study was conducted at a primary HIV-clinic in Lambaréné, Gabon. HIV-infected adults who were ART-naïve or exposed to ART for at least 3 months submitted one blood sample and stool and urine samples on 3 consecutive days. Outcome was helminth infection with intestinal helminths, Schistosoma haematobium, Loa loa or Mansonella perstans. Multivariable logistic regression was used to assess associations between ART or CTX-P and helminth infection. In total, 408 patients were enrolled. Helminth infection was common (77/252 [30.5%]). Filarial infections were most prevalent (55/310 [17.7%]), followed by infection with intestinal helminths (35/296 [11.8%]) and S. haematobium (19/323 [5.9%]). Patients on CTX-P had a reduced risk of Loa loa microfilaremia (adjusted odds ratio (aOR) 0.47, 95% CI 0.23-0.97, P = 0.04), also in the subgroup of patients on ART (aOR 0.36, 95% CI 0.13-0.96, P = 0.04). There was no effect of ART exposure on helminth infection prevalence.

Conclusions/Significance

CTX-P use was associated with a decreased risk of Loa loa infection, suggesting an anthelminthic effect of antifolate drugs. No relation between ART use and helminth infections was established.

The geographical distribution of helminth infections, which are highly prevalent in many areas, overlaps considerably with regions of high HIV sero-prevalence. The highest burden of infection is found in resource-poor settings, making it unattractive for the pharmaceutical industry to invest. Limited available treatment options and drug-resistance are increasing problems for soil-transmitted helminths, whereas for some other helminth infections, such as for the blood-dwelling microfilariae, effective and safe treatment options are still far from being optimal. Limited evidence suggests antihelminthic effects of antiretroviral therapy (ART) in HIV-infected individuals. We aimed to investigate whether ART or cotrimoxazole preventive treatment (CTX-P) reduces prevalence of helminth infection in HIV-infected individuals attending a primary HIV clinic in a semi-rural area in Gabon. The most important finding of our study was that the use of CTX-P was associated with a reduced prevalence of Loa loa microfilaremia. ART use was not associated with a reduced prevalence of helminth infections. Additional studies are needed to assess the effects of CTX on helminth infections, as this might be a promising safe and effective drug adding to the limited repertoire of anthelminthic drugs.

Treatment of W. bancrofti (Wb) in HIV/Wb coinfections in South India

Background

The disease course of human immunodeficiency virus (HIV) is often altered by existing or newly acquired coincident infections.

Methodology/Principal Findings

To assess the influence of pre-existing Wuchereria bancrofti infection on HIV progression, we performed a case-controlled treatment study of HIV positive individuals with (FIL+) or without (FIL-) W. bancrofti infection. Twenty-eight HIV+/FIL+ and 51 matched HIV+/FIL- subjects were treated with a single dose of diethylcarbamazine and albendazole (DEC/Alb) and followed for a year at regular intervals. Sixteen of the HIV+/FIL+ subjects (54%) and 28 of the HIV+/FIL- controls (57%) were on antiretroviral therapy (ART) during the study. Following treatment, no differences were noted in clinical outcomes between the 2 groups. There also was no significant difference between the groups in the HIV viral load at 12 months as a percentage of baseline viral load (HIV+/FIL+ group had on average 0.97 times the response of the HIV+/FIL- group, 95% CI 0.88, 1.07) between the groups. Furthermore, there were no significant differences found in either the change in viral load at 1, 3, or 6 months or in the change in CD4 count at 3, 6, or 12 months between the 2 groups.

Conclusions/Significance

We were unable to find a significant effect of W. bancrofti infection or its treatment on HIV clinical course or surrogate markers of HIV disease progression though we recognized that our study was limited by the smaller than predicted sample size and by the use of ART in half of the patients. Treatment of W. bancrofti coinfection in HIV positive subjects (as is usual in mass drug administration campaigns) did not represent an increased risk to the subjects, and should therefore be considered for PLWHA living in W. bancrofti endemic areas.

Trial Registration

ClinicalTrials.gov NCT00344279

In people living with HIV infection, simultaneous infections can adversely affect HIV disease. This has been seen with bacterial (tuberculosis), viral (cytomegalovirus), and parasitic infections (toxoplasmosis). Lymphatic filariasis is caused by a thin thread-like parasite that lives in the lymph vessels of infected people. It can cause significant disability. This infection is found in much of the same areas that high levels of HIV infection. We were interested in knowing if lymphatic filariasis changed the course of HIV infection in people with both diseases. In this study, the authors enrolled people in India who were living with HIV who either had or didn’t have filarial infection. All patients were treated for filariasis with 2 drugs, and then were followed for 1 year to see how their HIV disease progressed. No difference in HIV disease progression was found between the groups that did or did not have filariasis before treatment. The patients with HIV did well with the medicine for filariasis.

Interactions between malaria and HIV infections in pregnant women: a first report of the magnitude, clinical and laboratory features, and predictive factors in Kinshasa, the Democratic Republic of Congo

Background

HIV and malaria are among the leading causes of morbidity and mortality during pregnancy in Africa. However, data from Congolese pregnant women are lacking. The aim of the study was to determine the magnitude, predictive factors, clinical, biologic and anthropometric consequences of malaria infection, HIV infection, and interactions between malaria and HIV infections in pregnant women.

Methods

A cross-sectional study was conducted among pregnant women admitted and followed up at Camp Kokolo Military Hospital from 2009 to 2012 in Kinshasa, the Democratic Republic of Congo. Differences in means between malaria-positive and malaria-negative cases or between HIV-positive and HIV-negative cases were compared using the Student’s t-test or a non-parametric test, if appropriate. Categorical variables were compared using the Chi-square or Fisher’s exact test, if appropriate. Backward multivariable analysis was used to evaluate the potential risk factors of malaria and HIV infections. The odds ratios with their 95% confidence interval (95% CI) were estimated to measure the strengths of the associations. Analyses resulting in values of P < 0.05 were considered significant.

Results

A malaria infection was detected in 246/332 (74.1%) pregnant women, and 31.9% were anaemic. Overall, 7.5% (25/332) of mothers were infected by HIV, with a median CD4 count of 375 (191; 669) cells/μL. The mean (±SD) birth weight was 2,613 ± 227 g, with 35.7% of newborns weighing less than 2,500 g (low birth weight). Low birth weight, parity and occupation were significantly different between malaria-infected and uninfected women in adjusted models. However, fever, anemia, placenta previa, marital status and district of residence were significantly associated to HIV infection.

Conclusion

The prevalence of malaria infection was high in pregnant women attending the antenatal facilities or hospitalized and increased when associated with HIV infection.

Effect of deworming on disease progression markers in HIV-1-infected pregnant women on antiretroviral therapy: a longitudinal observational study from Rwanda

BACKGROUND

Deworming human immunodeficiency virus (HIV)-infected individuals on antiretroviral therapy (ART) may be beneficial, particularly during pregnancy. We determined the efficacy of targeted and nontargeted antihelminth therapy and its effects on Plasmodium falciparum infection status, hemoglobin levels, CD4 counts, and viral load in pregnant, HIV-positive women receiving ART.

METHODS

Nine hundred eighty HIV-infected pregnant women receiving ART were examined at 2 visits during pregnancy and 2 postpartum visits within 12 weeks. Women were given antimalarials when malaria-positive whereas albendazole was given in a targeted (n = 467; treatment when helminth stool screening was positive) or nontargeted (n = 513; treatment at all time points, with stool screening) fashion.

RESULTS

No significant differences were noted between targeted and nontargeted albendazole treatments for the variables measured at each study visit except for CD4 counts, which were lower (P < .05) in the latter group at the final visit. Albendazole therapy was associated with favorable changes in subjects' hemoglobin levels, CD4 counts, and viral loads, particularly with helminth infections.

CONCLUSIONS

Antihelminthic therapy reduces detectable viral load, and increases CD4 counts and hemoglobin levels in pregnant HIV-infected women with helminth coinfections receiving ART.

Water, sanitation, hygiene, and soil-transmitted helminth infection: a systematic review and meta-analysis

BACKGROUND

Preventive chemotherapy represents a powerful but short-term control strategy for soil-transmitted helminthiasis. Since humans are often re-infected rapidly, long-term solutions require improvements in water, sanitation, and hygiene (WASH). The purpose of this study was to quantitatively summarize the relationship between WASH access or practices and soil-transmitted helminth (STH) infection.

METHODS AND FINDINGS

We conducted a systematic review and meta-analysis to examine the associations of improved WASH on infection with STH (Ascaris lumbricoides, Trichuris trichiura, hookworm [Ancylostoma duodenale and Necator americanus], and Strongyloides stercoralis). PubMed, Embase, Web of Science, and LILACS were searched from inception to October 28, 2013 with no language restrictions. Studies were eligible for inclusion if they provided an estimate for the effect of WASH access or practices on STH infection. We assessed the quality of published studies with the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach. A total of 94 studies met our eligibility criteria; five were randomized controlled trials, whilst most others were cross-sectional studies. We used random-effects meta-analyses and analyzed only adjusted estimates to help account for heterogeneity and potential confounding respectively. Use of treated water was associated with lower odds of STH infection (odds ratio [OR] 0.46, 95% CI 0.36-0.60). Piped water access was associated with lower odds of A. lumbricoides (OR 0.40, 95% CI 0.39-0.41) and T. trichiura infection (OR 0.57, 95% CI 0.45-0.72), but not any STH infection (OR 0.93, 95% CI 0.28-3.11). Access to sanitation was associated with decreased likelihood of infection with any STH (OR 0.66, 95% CI 0.57-0.76), T. trichiura (OR 0.61, 95% CI 0.50-0.74), and A. lumbricoides (OR 0.62, 95% CI 0.44-0.88), but not with hookworm infection (OR 0.80, 95% CI 0.61-1.06). Wearing shoes was associated with reduced odds of hookworm infection (OR 0.29, 95% CI 0.18-0.47) and infection with any STH (OR 0.30, 95% CI 0.11-0.83). Handwashing, both before eating (OR 0.38, 95% CI 0.26-0.55) and after defecating (OR 0.45, 95% CI 0.35-0.58), was associated with lower odds of A. lumbricoides infection. Soap use or availability was significantly associated with lower infection with any STH (OR 0.53, 95% CI 0.29-0.98), as was handwashing after defecation (OR 0.47, 95% CI 0.24-0.90). Observational evidence constituted the majority of included literature, which limits any attempt to make causal inferences. Due to underlying heterogeneity across observational studies, the meta-analysis results reflect an average of many potentially distinct effects, not an average of one specific exposure-outcome relationship.

CONCLUSIONS

WASH access and practices are generally associated with reduced odds of STH infection. Pooled estimates from all meta-analyses, except for two, indicated at least a 33% reduction in odds of infection associated with individual WASH practices or access. Although most WASH interventions for STH have focused on sanitation, access to water and hygiene also appear to significantly reduce odds of infection. Overall quality of evidence was low due to the preponderance of observational studies, though recent randomized controlled trials have further underscored the benefit of handwashing interventions. Limited use of the Joint Monitoring Program's standardized water and sanitation definitions in the literature restricted efforts to generalize across studies. While further research is warranted to determine the magnitude of benefit from WASH interventions for STH control, these results call for multi-sectoral, integrated intervention packages that are tailored to social-ecological contexts.