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Kifude CM, Roberds A, Oyieko J, Ocholla S, Otieno S, Waitumbi JN, Hutter J, Smith H, Copeland NK, Luckhart S, Stewart VA. Initiation of anti-retroviral/Trimethoprim-Sulfamethoxazole therapy in a longitudinal cohort of HIV-1 positive individuals in Western Kenya rapidly decreases asymptomatic malarial parasitemia. Front Cell Infect Microbiol 2022; 12:1025944. [PMID: 36506016 PMCID: PMC9729353 DOI: 10.3389/fcimb.2022.1025944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 10/28/2022] [Indexed: 11/25/2022] Open
Abstract
Interactions between malaria and HIV-1 have important public health implications. Our previous cross-sectional studies showed significant associations between HIV-1 positivity and malarial parasitemia with an increased risk of gametocytemia. In this follow-up longitudinal study, we evaluated these associations to determine the magnitude of asymptomatic parasitemia over time, and to examine the effects of initiating Antiretroviral Therapy (ART) together with the broad-spectrum antibiotic Trimethoprim Sulfamethoxazole (TS) on asymptomatic parasitemia. 300 adult volunteers in a malaria holoendemic region in Western Kenya were enrolled and followed for six months. The study groups were composed of 102 HIV-1 negatives, 106 newly diagnosed HIV-1 positives and 92 HIV-1 positives who were already stable on ART/TS. Blood samples were collected monthly and asymptomatic malarial parasitemia determined using sensitive 18S qPCR. Results showed significantly higher malaria prevalence in the HIV-1 negative group (61.4%) (p=0.0001) compared to HIV-1 positives newly diagnosed (36.5%) and those stable on treatment (31.45%). Further, treatment with ART/TS had an impact on incidence of asymptomatic parasitemia. In volunteers who were malaria PCR-negative at enrollment, the median time to detectable asymptomatic infection was shorter for HIV-1 negatives (149 days) compared to the HIV-1 positives on treatment (171 days) (p=0.00136). Initiation of HIV treatment among the newly diagnosed led to a reduction in malarial parasitemia (expressed as 18S copy numbers/μl) by over 85.8% within one week of treatment and a further reduction by 96% after 2 weeks. We observed that while the impact of ART/TS on parasitemia was long term, treatment with antimalarial Artemether/Lumefantrine (AL) among the malaria RDT positives had a transient effect with individuals getting re-infected after short periods. As was expected, HIV-1 negative individuals had normal CD4+ levels throughout the study. However, CD4+ levels among HIV-1 positives who started treatment were low at enrollment but increased significantly within the first month of treatment. From our association analysis, the decline in parasitemia among the HIV-1 positives on treatment was attributed to TS treatment and not increased CD4+ levels per se. Overall, this study highlights important interactions between HIV-1 and malaria that may inform future use of TS among HIV-infected patients in malaria endemic regions.
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Affiliation(s)
- Carolyne M. Kifude
- Kombewa Clinical Research Center, Kenya Medical Research Institute-United States Army Medical Research Directorate-Africa, Kisumu, Kenya
| | - Ashleigh Roberds
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of Health Sciences, Bethesda, MD, United States
| | - Janet Oyieko
- Kombewa Clinical Research Center, Kenya Medical Research Institute-United States Army Medical Research Directorate-Africa, Kisumu, Kenya
| | - Stephen Ocholla
- Kombewa Clinical Research Center, Kenya Medical Research Institute-United States Army Medical Research Directorate-Africa, Kisumu, Kenya
| | - Solomon Otieno
- Kombewa Clinical Research Center, Kenya Medical Research Institute-United States Army Medical Research Directorate-Africa, Kisumu, Kenya
| | - John N. Waitumbi
- Kombewa Clinical Research Center, Kenya Medical Research Institute-United States Army Medical Research Directorate-Africa, Kisumu, Kenya
| | - Jack Hutter
- Kombewa Clinical Research Center, Kenya Medical Research Institute-United States Army Medical Research Directorate-Africa, Kisumu, Kenya
| | - Hunter Smith
- Kombewa Clinical Research Center, Kenya Medical Research Institute-United States Army Medical Research Directorate-Africa, Kisumu, Kenya
| | - Nathanial K. Copeland
- Kombewa Clinical Research Center, Kenya Medical Research Institute-United States Army Medical Research Directorate-Africa, Kisumu, Kenya
| | - Shirley Luckhart
- Department of Entomology, Plant Pathology and Nematology, University of Idaho, Moscow, ID, United States
- Department of Biological Sciences, University of Idaho, Moscow, ID, United States
| | - V. Ann Stewart
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of Health Sciences, Bethesda, MD, United States
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Shaffer D, Kumwenda J, Chen H, Akelo V, Angira F, Kosgei J, Tonui R, Ssali F, McKhann A, Hogg E, Stewart VA, Murphy SC, Coombs R, Schooley R. Brief Report: No Differences Between Lopinavir/Ritonavir and Nonnucleoside Reverse Transcriptase Inhibitor-Based Antiretroviral Therapy on Clearance of Plasmodium falciparum Subclinical Parasitemia in Adults Living With HIV Starting Treatment (A5297). J Acquir Immune Defic Syndr 2022; 89:178-182. [PMID: 34693933 PMCID: PMC9425486 DOI: 10.1097/qai.0000000000002839] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 09/20/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND HIV protease inhibitors anti-Plasmodium falciparum activity in adults remains uncertain. METHODS Adults with HIV CD4+ counts >200 cells/mm3 starting antiretroviral therapy (ART) with P. falciparum subclinical parasitemia (Pf SCP) were randomized 1:1 to (step 1) protease inhibitor lopinavir/ritonavir (LPV/r)-based (arm A) or nonnucleoside reverse transcriptase inhibitor (nNRTI)-based ART (arm B) for 15 days. In step 2, participants received nNRTI-based ART and trimethoprim/sulfamethoxazole prophylaxis for 15 days. P. falciparum SCP clearance was measured by polymerase chain reaction. The Fisher exact test [95% exact confidence interval (CI)] was used to compare proportions of P. falciparum SCP clearance (<10 parasites/μL on 3 occasions within 24 hours) between LPV/r and nNRTI arms at day 15. The Kaplan-Meier method and log-rank test were used to compare time-to-clearance. RESULTS Fifty-two adults from Kenya, Malawi, and Uganda with a median age = 31 (Q1, Q3: 24-39) years, 33% women, with baseline median CD4+ counts of 324 (259-404) cells/mm3, median HIV-1 RNA viremia of 5.18 log10 copies/mL (4.60-5.71), and median estimated P. falciparum density of 454 parasites/μL (83-2219) enrolled in the study. Forty-nine (94%) participants completed the study. At day 15, there was no statistically significant difference in the proportions of P. falciparum SCP clearance between the LPV/r (23.1% clearance; 6 of the 26) and nNRTI (26.9% clearance; 7 of the 26) arms [between-arm difference 3.9% (95% CI, -21.1% to 28.4%; P = 1.00)]. No significant difference in time-to-clearance was observed between the arms (P = 0.80). CONCLUSIONS In a small randomized study of adults starting ART with P. falciparum SCP, no statistically significant differences were seen between LPV/r- and nNRTI-based ART in P. falciparum SCP clearance after 15 days of treatment.
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Affiliation(s)
- Douglas Shaffer
- U.S. Centers for Disease Control and Prevention, Kigali, Rwanda (at time of research)
| | | | - Huichao Chen
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Victor Akelo
- Kenya Medical Research Institute, Center for Global Health (KEMRI/CGHR)/Emory-CDC CTU, Kisumu, Kenya
| | - Francis Angira
- Kenya Medical Research Institute, Center for Global Health (KEMRI/CGHR)/Emory-CDC CTU, Kisumu, Kenya
| | - Josphat Kosgei
- Kenya Medical Research Institute/United States Army Medical Research Directorate-Africa/Kenya, Kericho, Kenya
| | - Ronald Tonui
- Moi University School of Medicine, Eldoret, Kenya
| | | | - Ashley McKhann
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Evelyn Hogg
- Social & Scientific Systems, Inc., A DLH Holdings Company, Silver Spring, MD, USA
| | - V. Ann Stewart
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Sean C. Murphy
- Department of Laboratory Medicine and Pathology, University of Washington; Department of Microbiology, University of Washington; Center for Emerging and Re-emerging Infectious Diseases, University of Washington; Seattle, WA, USA
| | - Robert Coombs
- Department of Laboratory Medicine and Pathology; Department of Medicine, University of Washington, Seattle, WA, USA
| | - Robert Schooley
- Division of Infectious Diseases, Department of Medicine, University of California, San Diego, La Jolla, CA, USA
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Petersen JM, Ranker LR, Barnard-Mayers R, MacLehose RF, Fox MP. A systematic review of quantitative bias analysis applied to epidemiological research. Int J Epidemiol 2021; 50:1708-1730. [PMID: 33880532 DOI: 10.1093/ije/dyab061] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Quantitative bias analysis (QBA) measures study errors in terms of direction, magnitude and uncertainty. This systematic review aimed to describe how QBA has been applied in epidemiological research in 2006-19. METHODS We searched PubMed for English peer-reviewed studies applying QBA to real-data applications. We also included studies citing selected sources or which were identified in a previous QBA review in pharmacoepidemiology. For each study, we extracted the rationale, methodology, bias-adjusted results and interpretation and assessed factors associated with reproducibility. RESULTS Of the 238 studies, the majority were embedded within papers whose main inferences were drawn from conventional approaches as secondary (sensitivity) analyses to quantity-specific biases (52%) or to assess the extent of bias required to shift the point estimate to the null (25%); 10% were standalone papers. The most common approach was probabilistic (57%). Misclassification was modelled in 57%, uncontrolled confounder(s) in 40% and selection bias in 17%. Most did not consider multiple biases or correlations between errors. When specified, bias parameters came from the literature (48%) more often than internal validation studies (29%). The majority (60%) of analyses resulted in >10% change from the conventional point estimate; however, most investigators (63%) did not alter their original interpretation. Degree of reproducibility related to inclusion of code, formulas, sensitivity analyses and supplementary materials, as well as the QBA rationale. CONCLUSIONS QBA applications were rare though increased over time. Future investigators should reference good practices and include details to promote transparency and to serve as a reference for other researchers.
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Affiliation(s)
- Julie M Petersen
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Lynsie R Ranker
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Ruby Barnard-Mayers
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Richard F MacLehose
- Division of Epidemiology and Community Health, University of Minnesota, School of Public Health, Minneapolis, MN, USA
| | - Matthew P Fox
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA.,Department of Global Health, Boston University School of Public Health, Boston, MA, USA
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Abstract
INTRODUCTION Using the data of a trial on cotrimoxazole (CTX) cessation, we investigated the effect of different antiretroviral therapy (ART) regimens on the incidence of clinical malaria. METHODS During the cotrimoxazole cessation trial (ISRCTN44723643), HIV-infected Ugandan adults with CD4 at least 250 cells/μl were randomized to receive either CTX prophylaxis or placebo and were followed for a median of 2.5 years. Blood slides for malaria microscopy were examined at scheduled visits and at unscheduled visits when the participant felt unwell. CD4 cell counts were done 6-monthly. Malaria was defined as fever with a positive blood slide. ART regimens were categorized as nucleoside reverse transcriptase inhibitor (NRTI) only, non-nucleoside reverse transcriptase inhibitor (NNRTI)-containing or protease inhibitor containing. Malaria incidence was calculated using random effects Poisson regression to account for clustering of events. RESULTS Malaria incidence in the three ART regimen groups was 9.9 (3.6-27.4), 9.3 (8.3-10.4), and 3.5 (1.6-7.6) per 100 person-years, respectively. Incidence on protease inhibitors was lower than that on the other regimens with the results just reaching significance (adjusted rate ratio 0.4, 95% confidence interval = 0.2-1.0, comparing with NNRTI regimens). Stratification by CTX/placebo use gave similar results, without evidence of an interaction between the effects of CTX/placebo use and ART regimen. There was no evidence of an interaction between ART regimen and CD4 cell count. CONCLUSION There was some evidence that protease inhibitor-containing ART regimens may be associated with a lower clinical malaria incidence compared with other regimens. This effect was not modified by CTX use or CD4 cell count. The antimalarial properties of protease inhibitors may have clinical and public health importance.
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Altered Plasmodium falciparum Sensitivity to the Antiretroviral Protease Inhibitor Lopinavir Associated with Polymorphisms in pfmdr1. Antimicrob Agents Chemother 2016; 61:AAC.01949-16. [PMID: 27821443 DOI: 10.1128/aac.01949-16] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 10/31/2016] [Indexed: 01/14/2023] Open
Abstract
The HIV protease inhibitor lopinavir inhibits Plasmodium falciparum aspartic proteases (plasmepsins) and parasite development, and children receiving lopinavir-ritonavir experienced fewer episodes of malaria than those receiving other antiretroviral regimens. Resistance to lopinavir was selected in vitro over ∼9 months, with ∼4-fold decreased sensitivity. Whole-genome sequencing of resistant parasites showed a mutation and increased copy number in pfmdr1 and a mutation in a protein of unknown function, but no polymorphisms in plasmepsin genes.
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Hobbs CV, Gabriel EE, Kamthunzi P, Tegha G, Tauzie J, Petzold E, Barlow-Mosha L, Chi BH, Li Y, Ilmet T, Kirmse B, Neal J, Parikh S, Deygoo N, Jean Philippe P, Mofenson L, Prescott W, Chen J, Musoke P, Palumbo P, Duffy PE, Borkowsky W. Malaria in HIV-Infected Children Receiving HIV Protease-Inhibitor- Compared with Non-Nucleoside Reverse Transcriptase Inhibitor-Based Antiretroviral Therapy, IMPAACT P1068s, Substudy to P1060. PLoS One 2016; 11:e0165140. [PMID: 27936233 PMCID: PMC5147802 DOI: 10.1371/journal.pone.0165140] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 10/05/2016] [Indexed: 11/21/2022] Open
Abstract
Background HIV and malaria geographically overlap. HIV protease inhibitors kill malaria parasites in vitro and in vivo, but further evaluation in clinical studies is needed. Methods Thirty-one children from Malawi aged 4–62 months were followed every 3 months and at intercurrent illness visits for ≤47 months (September 2009-December 2011). We compared malaria parasite carriage by blood smear microscopy (BS) and confirmed clinical malaria incidence (CCM, or positive BS with malaria symptoms) in children initiated on HIV antiretroviral therapy (ART) with zidovudine, lamivudine, and either nevirapine (NVP), a non-nucleoside reverse transcriptase inhibitor, or lopinavir-ritonavir (LPV-rtv), a protease inhibitor. Results We found an association between increased time to recurrent positive BS, but not CCM, when anti-malarial treatment and LPV-rtv based ART were used concurrently and when accounting for a LPV-rtv and antimalarial treatment interaction (adjusted HR 0.39; 95% CI (0.17,0.89); p = 0.03). Conclusions LPV-rtv in combination with malaria treatment was associated with lower risk of recurrent positive BS, but not CCM, in HIV-infected children. Larger, randomized studies are needed to confirm these findings which may permit ART optimization for malaria-endemic settings. Trial Registration ClinicalTrials.gov NCT00719602
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Affiliation(s)
- Charlotte V. Hobbs
- Laboratory of Malaria Immunology and Vaccinology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, United States of America
- Department of Pediatrics, Division of Infectious Disease and Immunology, New York University School of Medicine, NY, United States of America
- Batson Children’s Hospital, Department of Pediatrics (Division of Infectious Diseases) and Department of Microbiology, University of Mississippi Medical Center, Jackson, MS, United States of America
- * E-mail:
| | - Erin E. Gabriel
- Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, United States of America
| | - Portia Kamthunzi
- Kamuzu Central Hospital, University of North Carolina at Chapel Hill Lilongwe Project, Lilongwe, Malawi
| | - Gerald Tegha
- Kamuzu Central Hospital, University of North Carolina at Chapel Hill Lilongwe Project, Lilongwe, Malawi
| | - Jean Tauzie
- Kamuzu Central Hospital, University of North Carolina at Chapel Hill Lilongwe Project, Lilongwe, Malawi
| | - Elizabeth Petzold
- Duke Clinical Research Institute, Durham, NC, United States of America
| | - Linda Barlow-Mosha
- Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Benjamin H. Chi
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Yonghua Li
- Department of Pediatrics, Division of Infectious Disease and Immunology, New York University School of Medicine, NY, United States of America
| | - Tiina Ilmet
- Department of Pediatrics, Division of Infectious Disease and Immunology, New York University School of Medicine, NY, United States of America
- Cornell Clinical Trials Unit, Weill Cornell Medicine, NY, United States of America
| | - Brian Kirmse
- Department of Pediatrics, Division of Medical Genetics, University of Mississippi Medical Center, Batson Children’s Hospital, Jackson, MS, United States of America
| | - Jillian Neal
- Laboratory of Malaria Immunology and Vaccinology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, United States of America
| | - Sunil Parikh
- Yale Schools of Public Health and Medicine, New Haven, Connecticut, United States of America
| | - Nagamah Deygoo
- Department of Pediatrics, Division of Infectious Disease and Immunology, New York University School of Medicine, NY, United States of America
| | - Patrick Jean Philippe
- HJF-DAIDS, a Division of the Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Contractor to NIAID, NIH, DHHS, Bethesda, MD, United States of America
| | - Lynne Mofenson
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, United States of America
| | - William Prescott
- HYDAS World Health, Inc., Hummelstown, PA, United States of America
| | - Jingyang Chen
- Laboratory of Malaria Immunology and Vaccinology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, United States of America
- Ben Towne Center for Childhood Cancer Research, Seattle Children’s Research Institute, the University of Washington, and the Fred Hutchinson Cancer Research Center, Seattle WA, United States of America
| | - Philippa Musoke
- Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda
- Department of Pediatrics and Child Health, Makerere University, Kampala, Uganda
| | - Paul Palumbo
- Division of Infectious Diseases and International Health, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, United States of America
| | - Patrick E. Duffy
- Laboratory of Malaria Immunology and Vaccinology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, United States of America
| | - William Borkowsky
- Department of Pediatrics, Division of Infectious Disease and Immunology, New York University School of Medicine, NY, United States of America
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Parikh S, Kajubi R, Huang L, Ssebuliba J, Kiconco S, Gao Q, Li F, Were M, Kakuru A, Achan J, Mwebaza N, Aweeka FT. Antiretroviral Choice for HIV Impacts Antimalarial Exposure and Treatment Outcomes in Ugandan Children. Clin Infect Dis 2016; 63:414-22. [PMID: 27143666 PMCID: PMC4946019 DOI: 10.1093/cid/ciw291] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 04/03/2016] [Indexed: 02/06/2023] Open
Abstract
Pharmacokinetic/pharmacodynamic studies of artemether-lumefantrine and 3 antiretroviral regimens were conducted in malaria-infected Ugandan children. Efavirenz-based treatment was associated with significant reductions in antimalarial exposure and higher risks of recurrent malaria. Caution in their concurrent use is warranted. Background. The optimal treatment of malaria in human immunodeficiency virus (HIV)–infected children requires consideration of critical drug–drug interactions in coinfected children, as these may significantly impact drug exposure and clinical outcomes. Methods. We conducted an intensive and sparse pharmacokinetic/pharmacodynamic study in Uganda of the most widely adopted artemisinin-based combination therapy, artemether-lumefantrine. HIV-infected children on 3 different first-line antiretroviral therapy (ART) regimens were compared to HIV-uninfected children not on ART, all of whom required treatment for Plasmodium falciparum malaria. Pharmacokinetic sampling for artemether, dihydroartemisinin, and lumefantrine exposure was conducted through day 21, and associations between drug exposure and outcomes through day 42 were investigated. Results. One hundred forty-five and 225 children were included in the intensive and sparse pharmacokinetic analyses, respectively. Compared with no ART, efavirenz (EFV) reduced exposure to all antimalarial components by 2.1- to 3.4-fold; lopinavir/ritonavir (LPV/r) increased lumefantrine exposure by 2.1-fold; and nevirapine reduced artemether exposure only. Day 7 concentrations of lumefantrine were 10-fold lower in children on EFV vs LPV/r-based ART, changes that were associated with an approximate 4-fold higher odds of recurrent malaria by day 28 in those on EFV vs LPV/r-based ART. Conclusions. The choice of ART in children living in a malaria-endemic region has highly significant impacts on the pharmacokinetics and pharmacodynamics of artemether-lumefantrine treatment. EFV-based ART reduces all antimalarial components and is associated with the highest risk of recurrent malaria following treatment. For those on EFV, close clinical follow-up for recurrent malaria following artemether-lumefantrine treatment, along with the study of modified dosing regimens that provide higher exposure, is warranted.
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Affiliation(s)
- Sunil Parikh
- Yale School of Public Health, New Haven, Connecticut
| | - Richard Kajubi
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Liusheng Huang
- University of California, San Francisco, and San Francisco General Hospital
| | | | - Sylvia Kiconco
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Qin Gao
- University of California, San Francisco, and San Francisco General Hospital
| | - Fangyong Li
- University of California, San Francisco, and San Francisco General Hospital
| | - Moses Were
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Abel Kakuru
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Jane Achan
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Norah Mwebaza
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Francesca T Aweeka
- University of California, San Francisco, and San Francisco General Hospital
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Hoglund RM, Byakika-Kibwika P, Lamorde M, Merry C, Ashton M, Hanpithakpong W, Day NPJ, White NJ, Äbelö A, Tarning J. Artemether-lumefantrine co-administration with antiretrovirals: population pharmacokinetics and dosing implications. Br J Clin Pharmacol 2015; 79:636-49. [PMID: 25297720 PMCID: PMC4386948 DOI: 10.1111/bcp.12529] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 10/03/2014] [Indexed: 11/29/2022] Open
Abstract
AIM Drug–drug interactions between antimalarial and antiretroviral drugs may influence antimalarial treatment outcomes. The aim of this study was to investigate the potential drug–drug interactions between the antimalarial drugs, lumefantrine, artemether and their respective metabolites desbutyl-lumefantrine and dihydroartemisinin, and the HIV drugs efavirenz, nevirapine and lopinavir/ritonavir. METHOD Data from two clinical studies, investigating the influence of the HIV drugs efavirenz, nevirapine and lopinavir/ritonavir on the pharmacokinetics of the antimalarial drugs lumefantrine, artemether and their respective metabolites, in HIV infected patients were pooled and analyzed using a non-linear mixed effects modelling approach. RESULTS Efavirenz and nevirapine significantly decreased the terminal exposure to lumefantrine (decrease of 69.9% and 25.2%, respectively) while lopinavir/ritonavir substantially increased the exposure (increase of 439%). All antiretroviral drugs decreased the total exposure to dihydroartemisinin (decrease of 71.7%, 41.3% and 59.7% for efavirenz, nevirapine and ritonavir/lopinavir, respectively). Simulations suggest that a substantially increased artemether-lumefantrine dose is required to achieve equivalent exposures when co-administered with efavirenz (250% increase) and nevirapine (75% increase). When co-administered with lopinavir/ritonavir it is unclear if the increased lumefantrine exposure compensates adequately for the reduced dihydroartemisinin exposure and thus whether dose adjustment is required. CONCLUSION There are substantial drug interactions between artemether-lumefantrine and efavirenz, nevirapine and ritonavir/lopinavir. Given the readily saturable absorption of lumefantrine, the dose adjustments predicted to be necessary will need to be evaluated prospectively in malaria-HIV co-infected patients.
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Affiliation(s)
- Richard M Hoglund
- Unit for Pharmacokinetics and Drug Metabolism, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
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Orlov M, Smeaton LM, Kumwenda J, Hosseinipour MC, Campbell TB, Schooley RT. Presence of Plasmodium falciparum DNA in Plasma Does Not Predict Clinical Malaria in an HIV-1 Infected Population. PLoS One 2015; 10:e0129519. [PMID: 26053030 PMCID: PMC4460081 DOI: 10.1371/journal.pone.0129519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2014] [Accepted: 05/08/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND HIV-1 and Plasmodium falciparum malaria cause substantial morbidity in Sub-Saharan Africa, especially as co-infecting pathogens. We examined the relationship between presence of P. falciparum DNA in plasma samples and clinical malaria as well as the impact of atazanavir, an HIV-1 protease inhibitor (PI), on P. falciparum PCR positivity. METHODS ACTG study A5175 compared two NNRTI-based regimens and one PI-based anti-retroviral (ARV) regimen in antiretroviral therapy naïve participants. We performed nested PCR on plasma samples for the P. falciparum 18s rRNA gene to detect the presence of malaria DNA in 215 of the 221 participants enrolled in Blantyre and Lilongwe, Malawi. We also studied the closest sample preceding the first malaria diagnosis from 102 persons with clinical malaria and randomly selected follow up samples from 88 persons without clinical malaria. RESULTS PCR positivity was observed in 18 (8%) baseline samples and was not significantly associated with age, sex, screening CD4+ T-cell count, baseline HIV-1 RNA level or co-trimoxazole use within the first 8 weeks. Neither baseline PCR positivity (p = 0.45) nor PCR positivity after initiation of antiretroviral therapy (p = 1.0) were significantly associated with subsequent clinical malaria. Randomization to the PI versus NNRTI ARV regimens was not significantly associated with either PCR positivity (p = 0.5) or clinical malaria (p = 0.609). Clinical malaria was associated with a history of tuberculosis (p = 0.006) and a lower BMI (p = 0.004). CONCLUSION P. falciparum DNA was detected in 8% of participants at baseline, but was not significantly associated with subsequent development of clinical malaria. HIV PI therapy did not decrease the prevalence of PCR positivity or incidence of clinical disease.
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Affiliation(s)
- Marika Orlov
- School of Medicine, University of California San Diego, San Diego, California, United States of America
| | - Laura M Smeaton
- Center for Biostatistics in AIDS Research, Harvard School of Public Health, Boston, Massachusetts, United States of America
| | | | - Mina C Hosseinipour
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America; University of North Carolina Project, Lilongwe, Malawi
| | - Thomas B Campbell
- School of Medicine, University of Colorado, Aurora, Colorado, United States of America
| | - Robert T Schooley
- School of Medicine, University of California San Diego, San Diego, California, United States of America
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Qin L, Qin L, Xu W, Zhao S, Chen X. Ritonavir-boosted indinavir but not lopinavir inhibits erythrocytic stage Plasmodium knowlesi malaria in rhesus macaques. Bioorg Med Chem Lett 2015; 25:1538-40. [PMID: 25704890 DOI: 10.1016/j.bmcl.2015.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 02/02/2015] [Accepted: 02/07/2015] [Indexed: 11/28/2022]
Abstract
The inhibitive activities of the human immunodeficiency virus protease inhibitors ritonavir (RTV) boosted indinavir (IDV) and RTV boosted lopinavir (LPV) for erythrocytic stage malaria were evaluated in rhesus macaques. The IDV/RTV regimen effectively inhibits the replication of Plasmodium knowlesi with clinically relevant doses, whereas the LPV/RTV regimen did not show activity against plasmodium infection.
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Affiliation(s)
- Li Qin
- Laboratory of Pathogen Biology, State Key Laboratory of Respiratory Disease, Center for Infection and Immunity, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, No. 190, Kaiyuan Avenue, Guangzhou Science Park, Guangzhou 510530, China
| | - Limei Qin
- Laboratory of Pathogen Biology, State Key Laboratory of Respiratory Disease, Center for Infection and Immunity, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, No. 190, Kaiyuan Avenue, Guangzhou Science Park, Guangzhou 510530, China
| | - Wanwan Xu
- Laboratory of Pathogen Biology, State Key Laboratory of Respiratory Disease, Center for Infection and Immunity, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, No. 190, Kaiyuan Avenue, Guangzhou Science Park, Guangzhou 510530, China
| | - Siting Zhao
- Laboratory of Pathogen Biology, State Key Laboratory of Respiratory Disease, Center for Infection and Immunity, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, No. 190, Kaiyuan Avenue, Guangzhou Science Park, Guangzhou 510530, China
| | - Xiaoping Chen
- Laboratory of Pathogen Biology, State Key Laboratory of Respiratory Disease, Center for Infection and Immunity, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, No. 190, Kaiyuan Avenue, Guangzhou Science Park, Guangzhou 510530, China.
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Ahmed BS, Phelps BR, Reuben EB, Ferris RE. Does a significant reduction in malaria risk make lopinavir/ritonavir-based ART cost-effective for children with HIV in co-endemic, low-resource settings? Trans R Soc Trop Med Hyg 2013; 108:49-54. [PMID: 24300443 DOI: 10.1093/trstmh/trt108] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND HIV infection and malaria co-infection is not uncommon among children in co-endemic regions, and evidence suggests that HIV is a risk factor for severe malaria among children. HIV protease inhibitors (PIs) are highly effective in pediatric HIV treatment regimens, however, their effectiveness against malaria has been mixed, with some PIs demonstrating in vitro activity against Plasmodium falciparum. Recent findings suggest lopinavir/ritonavir (LPV/r)-based treatment regimens reduce the incidence of malaria infection by over 40% in pediatric HIV patients compared to non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimens. METHODS We assessed whether a significant reduction in malaria risk makes LPV/r-based ART regimens cost-effective compared to NNRTI-based regimens in co-endemic, low-resource settings. We modeled the difference in unit cost per disability adjusted life year (DALY) gained among two theoretical groups of HIV+ children under 5 years old receiving ART in a resource-limited setting co-endemic for malaria. The first group received standard NNRTI-based antiretrovirals, the second group received a standard regimen containing LPV/r. We used recent cohort data for the incidence reduction for malaria. Drug costs were taken from the 2011 Clinton Health Access Initiative Antiretroviral (ARV) ceiling price list. DALYs for HIV and malaria were derived from WHO estimates. RESULTS Our model suggests a unit cost of US$147 per DALY gained for the LPV/r-based group compared to US$37 per DALY gained for the NNRTI-based group. CONCLUSION In HIV and malaria co-endemic settings, considerations of PI cost effectiveness incorporating known reductions in malaria mortality suggest a nominal increase in DALYs gained for PIs over NNRTI-based regimens for HIV positive children under five on ART. Our analysis was based on several assumptions due to lack of sound data on malaria and HIV DALY attribution among pediatric populations. Further study in this area is required.
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Affiliation(s)
- Bilaal S Ahmed
- United States Agency for International Development, Office of HIV/AIDS, 1300 Pennsylvania Ave., Washington, DC 20523, USA
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Ivan E, Crowther NJ, Mutimura E, Osuwat LO, Janssen S, Grobusch MP. Helminthic infections rates and malaria in HIV-infected pregnant women on anti-retroviral therapy in Rwanda. PLoS Negl Trop Dis 2013; 7:e2380. [PMID: 23967365 PMCID: PMC3744439 DOI: 10.1371/journal.pntd.0002380] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2013] [Accepted: 07/10/2013] [Indexed: 02/02/2023] Open
Abstract
Background Within sub-Saharan Africa, helminth and malaria infections cause considerable morbidity in HIV-positive pregnant women and their offspring. Helminth infections are also associated with a higher risk of mother-to-child HIV transmission. The aim of this study was to determine the prevalence of, and the protective and risk factors for helminth and malaria infections in pregnant HIV-positive Rwandan women receiving anti-retroviral therapy (ART). Methodology and principle findings Pregnant females (n = 980) were recruited from health centres in rural and peri-urban locations in the central and eastern provinces of Rwanda. Helminth infection was diagnosed using the Kato Katz method whilst the presence of Plasmodium falciparum was identified from blood smears. The prevalence of helminth infections was 34.3%; of malaria 13.3%, and of co-infections 6.6%. Helminth infections were more common in rural (43.1%) than peri-urban (18.0%; p<0.0005) sites. A CD4 count ≤350 cells/mm3 was associated with a higher risk of helminth infections (odds ratio, 3.39; 95% CIs, 2.16–5.33; p<0.0005) and malaria (3.37 [2.11–5.38]; p<0.0005) whilst helminth infection was a risk factor for malaria infection and vice versa. Education and employment reduced the risk of all types of infection whilst hand washing protected against helminth infection (0.29 [0.19–0.46]; p<0.0005);). The TDF-3TC-NVP (3.47 [2.21–5.45]; p<0.0005), D4T-3TC-NVP (2.47 [1.27–4.80]; p<0.05) and AZT-NVP (2.60 [1.33–5.08]; p<0.05) regimens each yielded higher helminth infection rates than the AZT-3TC-NVP regimen. Anti-retroviral therapy had no effect on the risk of malaria. Conclusion/significance HIV-positive pregnant women would benefit from the scaling up of de-worming programs alongside health education and hygiene interventions. The differential effect of certain ART combinations (as observed here most strongly with AZT-3TC-NVP) possibly protecting against helminth infection warrants further investigation. There is an overlap in the worldwide distribution of intestinal worms (helminths), malaria and HIV. Co-infections with helminth and malaria parasites cause a significant problem in the host, particularly in the presence of HIV infection. The aim of this study was to assess the prevalence of intestinal worm and malaria infection and co-infections and the associated risk factors among HIV-positive pregnant women that attended rural and peri-urban health centers in Rwanda. Our findings indicate that intestinal worms were more common among HIV-infected pregnant women in the rural than peri-urban settings. HIV-positive pregnant women who had lower CD4 cell counts were more at risk of being infected by intestinal worms and malaria. Malaria also increased the risk of being infected by intestinal worms and vice versa. Socio-economic factors such as lack of education and unemployment were among the risk factors for intestinal worm infections and malaria. Hand washing was found to reduce the risk for worm infections; whilst one particular ART combination (AZT-3TC-NVP) led to a reduced rate of helminth infections when compared to others.
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Affiliation(s)
- Emil Ivan
- Kigali Health Institute Department of Biomedical Laboratory Sciences, Kigali, Rwanda
- Rwanda Biomedical Centre National Reference Laboratory, Department of Laboratory Network, Kigali, Rwanda
- Department of Chemical Pathology, University of the Witwatersrand Medical School, National Health Laboratory Services, Parktown, Johannesburg, South Africa
| | - Nigel J. Crowther
- Department of Chemical Pathology, University of the Witwatersrand Medical School, National Health Laboratory Services, Parktown, Johannesburg, South Africa
| | - Eugene Mutimura
- Women Equity in Access to Care and Treatment (WE-ACTx), Kigali, Rwanda and Regional Alliance for Sustainable Development (RASD Rwanda), Kigali, Rwanda
| | - Lawrence Obado Osuwat
- Department of Medical Laboratory Science, School of Health Sciences, Mount Kenya University, Kigali, Rwanda
| | - Saskia Janssen
- Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany
- Center of Tropical Medicine and Travel Medicine, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Martin P. Grobusch
- Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany
- Center of Tropical Medicine and Travel Medicine, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- * E-mail:
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HIV-1 protease inhibitors for treatment of visceral leishmaniasis in HIV-co-infected individuals. THE LANCET. INFECTIOUS DISEASES 2013; 13:251-9. [DOI: 10.1016/s1473-3099(12)70348-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Ikilezi G, Achan J, Kakuru A, Ruel T, Charlebois E, Clark TD, Rosenthal PJ, Havlir D, Kamya MR, Dorsey G. Prevalence of asymptomatic parasitemia and gametocytemia among HIV-infected Ugandan children randomized to receive different antiretroviral therapies. Am J Trop Med Hyg 2013; 88:744-6. [PMID: 23358639 DOI: 10.4269/ajtmh.12-0658] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
In a recent randomized controlled trial, the use of protease inhibitor (PI)-based antiretroviral therapy (ART) was associated with a significantly lower incidence of malaria compared with non-nucleoside reverse transcriptase inhibitor-based ART in a cohort of human immunodeficiency virus-infected Ugandan children living in an area of high malaria transmission intensity. In this report, we compared the prevalence of asymptomatic parasitemia and gametocytemia using data from the same cohort. The prevalence of asymptomatic parasitemia did not differ between the two ART treatment arms. The PI-based arm was associated with a lower risk of gametocytemia at the time of diagnosis of malaria (6.6% versus 14.5%, P = 0.03) and during the 28 days after malaria diagnosis (3.4% versus 6.5%, P = 0.04). Thus, in addition to decreasing the incidence of malaria, the use of PI-based ART may lower transmission, as a result of a decrease in gametocytemia, in areas of high malaria transmission intensity.
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Affiliation(s)
- Gloria Ikilezi
- Infectious Diseases Research Collaboration, Kampala, Uganda.
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