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Am J Trop Med Hyg. 1996;55(1 Suppl):42-9.

Impairment of a pregnant woman's acquired ability to limit Plasmodium falciparum by infection with human immunodeficiency virus type-1.

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Division of Parasitic Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.


In Africa, the human immunodeficiency virus (HIV) is the most serious emerging infection and Plasmodium falciparum malaria is one of the most prevalent infectious diseases. Both infections have serious consequences in pregnant women, their fetuses, and infants. We examined the association between HIV and P. falciparum in pregnant women enrolled in a malaria chemoprophylaxis study in rural Malawi. Pregnant women (n = 2,946) were enrolled at their first antenatal clinic visit (mean 5.6 months of pregnancy), placed on one of three chloroquine regimens, and followed through delivery. Plasmodium falciparum parasitemia was measured at enrollment, monthly thereafter, at delivery, and 2-6 months postpartum; placental and newborn (umbilical cord blood) infection was measured for hospital-delivered infants. Serum collected during pregnancy was tested for antibodies to HIV by enzyme-linked immunoassay with Western blot confirmation. Parasitemia was detected in 46% of 2,946 women at enrollment and 19.1% at delivery; HIV seroprevalence was 5.5%. The prevalence and geometric mean density (GMPD) of parasitemia at enrollment and at delivery were higher in HIV-seropositive(+) than in HIV-seronegative(-) women (at enrollment: 57% prevalence and a GMPD of 1,558 parasites/mm3 versus 44% and 670/mm3, respectively; P < 0.0001; and at delivery: 35% and 1,589/mm3 versus 18% and 373/mm3; P < 0.0005). Placental infection rates were higher in HIV(+) compared with HIV(-) women, (38% versus 23%; P < 0.0005). This association was strongest in multigravidas. Compared with infants born to HIV(-) women, newborns born to HIV(+) women had higher rates of umbilical cord blood parasitemia. Both HIV(+) and HIV(-) women had similar rates of parasitemia 2-6 months postpartum. The HIV infection diminishes a pregnant woman's capacity to control P. falciparum parasitemia and placental and newborn infection, the major determinants of the impact of P. falciparum on fetal growth and infant survival.


During September 1987 to July 1989, in Malawi, clinical investigators enrolled 2946 pregnant women into a chemoprophylaxis study at their first prenatal care visit (mean, 5.6 months) at 4 rural sites in Mangochi District. They prescribed 1 of 3 chloroquine regimens to the women and followed them through delivery. The investigators measured Plasmodium falciparum parasitemia at enrollment, monthly thereafter, at delivery, and 2-6 months postpartum. For hospitalized infants, they measured parasitemia in the placenta and in the umbilical cord blood of the newborn. They also aimed to examine the association between HIV infection and malaria in pregnant women. 152 (5.5%) of the 2781 women for whom HIV test results and malaria blood smear examinations were available had confirmed HIV infection. Malaria parasitemia stood at 42% at enrollment and 19.1% at delivery. At enrollment, HIV-positive women had a higher malaria parasite prevalence rate than HIV-negative women (54.4% vs. 41.7%; relative risk [RR] = 1.31; p = 0.002). They also had a higher geometric mean density of parasitemia (1558 vs. 670/sq mm; p 0.0005). The parasite pattern was similar at delivery (34.7% vs. 18.2% [RR = 1.91] and 1589 vs. 373/sq mm, respectively; p 0.0005). The placenta of infants born in the hospital to HIV-positive mothers also had a higher prevalence of malaria parasites than those born in the hospital to HIV-negative mothers (38.2% vs. 22.5%; RR = 1.7; p = 0.0003). The prevalence of umbilical cord blood malaria infection was higher in infants born in the hospital to HIV-positive mothers than their counterparts (25.5% vs. 6.8%; RR = 3.76). At 2-6 months postpartum, the prevalence and density of malaria parasitemia rate did not differ significantly by HIV status. Parasitemia prevalence and density were higher in multigravida HIV-positive women than HIV-negative women but were similar in primigravid HIV-positive and HIV-negative women. These findings suggest that HIV infection reduces a pregnant woman's capacity to control P. falciparum parasitemia and placental and newborn infection.

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