Intermittent Preventive Treatment With Dihydroartemisinin-Piperaquine for the Prevention of Malaria Among HIV-Infected Pregnant Women

Abstract

Background: Daily trimethoprim-sulfamethoxazole (TMP-SMX) and insecticide-treated nets remain the main interventions for prevention of malaria in human immunodeficiency virus (HIV)-infected pregnant women in Africa. However, antifolate and pyrethroid resistance threaten the effectiveness of these interventions, and new ones are needed.

Methods: We conducted a double-blinded, randomized, placebo-controlled trial comparing daily TMP-SMX plus monthly dihydroartemisinin-piperaquine (DP) to daily TMP-SMX alone in HIV-infected pregnant women in an area of Uganda where indoor residual spraying of insecticide had recently been implemented. Participants were enrolled between gestation weeks 12 and 28 and given an insecticide-treated net. The primary outcome was detection of active or past placental malarial infection by histopathologic analysis. Secondary outcomes included incidence of malaria, parasite prevalence, and adverse birth outcomes.

Result: All 200 women enrolled were followed through delivery, and the primary outcome was assessed in 194. There was no statistically significant difference in the risk of histopathologically detected placental malarial infection between the daily TMP-SMX plus DP arm and the daily TMP-SMX alone arm (6.1% vs. 3.1%; relative risk, 1.96; 95% confidence interval, .50-7.61; P = .50). Similarly, there were no differences in secondary outcomes.

Conclusions: Among HIV-infected pregnant women in the setting of indoor residual spraying of insecticide, adding monthly DP to daily TMP-SMX did not reduce the risk of placental or maternal malaria or improve birth outcomes.

Clinical trials registration: NCT02282293.

Keywords: HIV; dihydroartemisinin-piperaquine; malaria; pregnancy; trimethoprim-sulfamethoxazole.

Copyright © 2017 European Crohn's and Colitis Organisation (ECCO). Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com

Figures

Figure 1.

Trial profile. Abbreviations: DP, dihydroartemisinin-piperaquine; HIV, human immunodeficiency virus; TMP-SMX, trimethoprim-sulfamethoxazole.

Figure 2.

Risk of any placental malarial infection detection by histopathologic analysis among study participants, stratified by gravidity. Black bars denote the arm that received trimethoprim-sulfamethoxazole (TMP-SMX) daily. Gray bars denote the arm that received TMP-SMX daily and dihydroartemisinin-piperaquine monthly. Error bars indicate upper limits of 95% confidence intervals.