Dihydroartemisinin-piperaquine does not reduce risk for malaria in pregnant women with HIV

Daily trimethoprim-sulfamethoxazole plus monthly dihydroartemisinin-piperaquine did not significantly reduce the risk of placental malaria in Ugandan pregnant women with HIV, according to data from a randomized trial.

“Artemisinin-based combination therapies have been shown to be effective for the treatment of malaria in pregnancy; however, there are limited data on the use of [these therapies] for the prevention of malaria in pregnancy and no published studies among HIV–infected women,” Paul Natureeba, MBChB, of Infectious Diseases Research Collaboration, Kampala, Uganda, and colleagues wrote. “Recent data from Kenya and Uganda showed that intermittent preventive treatment with dihydroartemisinin-piperaquine was associated with a lower burden of malaria compared with intermittent preventive treatment with sulfadoxine-pyrimethamine among HIV–uninfected pregnant women.”

The researchers performed a double blind, randomized, placebo-controlled trial in which 200 Ugandan women were randomly assigned to either daily trimethoprim-sulfamethoxazole plus monthly dihydroartemisinin-piperaquine or daily trimethoprim-sulfamethoxazole alone. All women lived in a region of Uganda where indoor insecticide spraying had been recently implemented. The main outcome was active or past infection of placental malaria, and secondary outcomes were incidence of malaria, adverse birth outcomes and parasite prevalence.

Mean age was 30 years. Roughly half (55%) of women were 20 weeks gestational age or less. Fifty-seven percent reported having an insecticide-treated net. Nearly all (91%) women were already receiving trimethoprim-sulfamethoxazole prophylaxis. Eighty-one percent were undergoing ART, and 68% had been on ART for at least 90 days before being enrolled in the study. Nine percent had malarial parasites detected.

Natureeba and colleagues wrote that they found no statistically significant difference in risk for placental malaria between groups (6.1% for trimethoprim-sulfamethoxazole plus dihydroartemisinin-piperaquine vs. 3.1% for trimethoprim-sulfamethoxazole alone, RR = 1.96; 95% CI, 0.5-7.61). The researchers did not report any statistically significant differences between the two groups in any secondary outcomes.

“In summary, the burden of malaria was relatively low among our population of HIV–infected pregnant women in the setting of daily trimethoprim-sulfamethoxazole prophylaxis, efavirenz-based ART, insecticide-treated nets and residual spraying of insecticides,” the researchers wrote. “The addition of intermittent preventive treatment with monthly dihydroartemisinin-piperaquine appeared to be safe and well tolerated, but did not provide any additional protection against malaria. Future studies of intermittent preventive treatment with dihydroartemisinin-piperaquine among HIV–infected pregnant women should be considered in areas where the burden of malaria is higher.” – by Andy Polhamus

Disclosure: The researchers report no relevant financial disclosures.