Malarial Morbidity and Postnatal HIV Infection in Breastfeeding HIV-exposed Infants
Amara E. Ezeamama *
Department of Epidemiology and Biostatistics, The University of Georgia, B.S. Miller Hall Room 125, 101 Buck Rd, Athens, GA 30602, USA.
Christopher Duggan
Department of Nutrition, Harvard School of Public Health (HSPH), Boston, MA, USA and Division of Gastroenterology and Nutrition, Children's Hospital, Boston, MA, USA.
Donna Spiegelman
Department of Epidemiology, HSPH, Boston, MA, USA and Department of Biostatistics, HSPH, Boston, MA, USA.
Ellen Hertzmark
Department of Biostatistics, HSPH, Boston, MA, USA.
Ronald J. Bosch
Center for Biostatistics in AIDS Research, HSPH, Boston, MA, USA.
Karim P. Manji
Department of Pediatrics and Child Health, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
Roland Kupka
Department of Nutrition, Harvard School of Public Health (HSPH), Boston, MA, USA and United Nations Children’s Fund, Regional Office for West and Central Africa, PO Box 29720, Dakar-Yoff, Senegal.
Melanie W. Lo
University of Minnesota Medical School, MN, USA.
James O. Okuma
Department of Nutrition, Harvard School of Public Health (HSPH), Boston, MA, USA.
Rodrick Kisenge
Department of Pediatrics and Child Health, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
Said Aboud
Department of Pediatrics and Child Health, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania and Department of Microbiology and Immunology, MuhimbiliUniversity of Health and Allied Sciences, United Nations Road, Upanga, P.O. Box 65001, Dar es Salaam, Tanzania.
Wafaie W. Fawzi
Department of Nutrition, Harvard School of Public Health (HSPH), Boston, MA, USA and Department of Epidemiology, HSPH, Boston, MA, USA and Department of Global Health and Population, HSPH, Boston, MA, USA.
*Author to whom correspondence should be addressed.
Abstract
Background: For at-risk HIV-negative individuals, whether malarial morbidity increases the likelihood of HIV infection when exposed is unknown. Hence, we investigate the malaria-associated risk of postnatal HIV infection in 1804 breastfeeding infants of HIV-positive women from Dar es Salaam, Tanzania.
Methods: Six-week-old HIV-negative infants were followed until breastfeeding cessation or postnatal HIV infection. HIV-1 status was determined by a DNA PCR test. Malarial morbidity was diagnosed by physicians using a combination of clinical symptoms and laboratory tests. For analytic purposes, malaria was distinguished by diagnostic specificity as: (1) clinical; (2) probable, where laboratory testing is requested for parasitemia; and (3) blood smear-confirmed. Hazard ratios (HR) and 95% confidence intervals (CI) for the risk of HIV infection were estimated from multivariate Cox regression models.
Results: Mean follow-up duration was 6.2 months (standard deviation=2.4 months), during which 91 new HIV infections developed and clinical malaria was diagnosed in 594(32.3%) children, including 283 (15.5%) probable and 80(4.4%) confirmed malaria episodes. Infants ever diagnosed with clinical and probable malaria were at 73% (95%CI:1.11 - 2.69) and 100% (95%CI:1.17-3.42) higher risk of postnatal HIV infection, respectively. This risk increased by 39% (95%CI: 1.08-1.80) and 59% (95%CI: 1.00-2.32), respectively, per episode increment in clinical and probable malarial; however, confirmed malaria was not significantly associated with HIV incidence (HR=2.09; 95%CI: 0.74 - 5.91).
Conclusion: We found positive associations between child malarial infection and postnatal HIV infection among breastfeeding HIV-negative children of HIV-positive women. These findings suggest that malaria prevention in such infants may decrease the risk of HIV mother-to-child-transmission. However, specific future studies using laboratory-confirmed malaria in HIV-negative but HIV at risk populations are needed to substantiate these findings.
Keywords: HIV/AIDS, malaria, co-infection, children, hiv incidence, breastfeeding, Sub-Saharan Africa