Printer Friendly

HIV and malaria co-infection in Mumbai, western India.


Malaria is endemic in many areas of India and repeated infections with Plasmodium falciparum and P. vivax occur. Malaria parasitemia differs in instances of asymptomatic and clinical malaria and the degree of parasitemia may influence the pathological and biochemical presentations in these patients (1,2). Influence of therapy to avoid HIV on malaria infection is controversial. Available studies have limited sample sizes and failed to demonstrate any association of malaria with HIV among hospitalized patients from areas with stable malaria transmission (3). It has been postulated that HIV infection alters clinical presentation of malaria (4). Further, treatment failure of anti-malarials is reported in HIV patients (5,6) which also has been contradicted (7). Fever, a major manifestation present both in HIV and malaria patients is not only due to infection, but also of many other common infections. An immune reconstitution syndrome along with adverse effects of antiretroviral drugs and other medicines lead to a febrile illness too (5,6). The fact that people in malaria endemic areas may have asymptomatic malarial parasitemia that complicates the diagnosis of febrile illness in malaria and HIV co-infected patients.

Survivors suffer chronic immune activation on repeated infection with increased susceptibility even in HIV negative individuals (8). High prevalence of HIV in Africa aggravates it to a greater extent. Malaria increases HIV viral load as much as 10-fold, increasing contagiousness of HIV infected persons and affecting the population epidemiology dynamics (9). Individuals in malaria endemic areas have a higher probability of sexual contact with persons who are infected with both malaria and HIV, with high viral load. Models of malaria-HIV interaction estimate a three fold increase in HIV transmission in malaria endemic populations and increased malaria transmission due to HIV co-infection (9).

Our current understanding of the human immune response to malaria and HIV leads us to expect that either of the infection might influence the clinical course of the other. Many other types of infections are associated with at least a transient increase in HIV viral load. Hence, it is logical to expect malaria to do the same and potentially to accelerate HIV disease progression. On the other hand, the control of malaria parasitemia is immune mediated, and this prevents most malarial infections from becoming clinically apparent in semi-immune adults in endemic areas (10,11). The immune deficiency caused by HIV infection should in theory, reduce the immune response to malaria parasitemia and, therefore, increase the frequency of clinical attacks of malaria.

However, as research evidence emerged from sub-Saharan Africa in the 1980s and 1990s (3), it soon became clear that malaria is not a typical opportunistic infection. In fact, the interaction between HIV and malaria has proved to be remarkably subtle, and it is only in the past few years that a clearer picture of this association has begun to emerge. The current study describes the occurrence of malaria and HIV co-infection in hospitalized malaria adult patients of malaria in Mumbai.


A total of 171 malaria patients with high-grade fever (38-45[degrees]C) for 3-8 days admitted to the medicine ward of KEM Hospital at Mumbai were enrolled in the study. Blood samples (5 ml) were collected aseptically at the time of admission for full blood count, erythrocyte sedimentation rate (ESR) and peripheral smears (thick and thin films for malaria parasite examined by two experts for confirmation of species). The serum was separated and stored at -20[degrees]C. These patients were confirmed for the malaria parasite in peripheral blood smears and the density showed varied numbers (<1-5%). These malaria patients tested for HIV-1 & 2 antibodies by two independent ELISA assays (Enzaids & J Mitra kits) and confirmed by western blot assay (Innogenetics, Belgium) following the manufacturer's protocol. The controls were normal blood bank volunteer donors who tested for HIV1 & 2 antibodies by ELISA kits confirmed by western blot. The local ethical committee approved the study.


Our results showed that 13 (7.6%) out of 171 malaria patients and 521 (1.81%) out of 28,749 blood bank donors were HIV-1 & 2 seroreactive (Table 1). Five of 13 malaria patients were confirmed to have HIV-1 infection, and the remaining eight patients showed borderline ELISA reactive results and indeterminate status on western blot analysis (Table 2). Our results of malaria and HIV-1 co-infection were highly significant.


Infection with HIV-1 causes progressive cellular immunosuppression, and any resulting impairment in the immune response to malaria might be associated with failure to prevent infection or to suppress parasitemia and clinical disease (12). However, laboratory-based studies have found that although some components of the human immune response to P. falciparum are modified by HIV1, others are unaffected (10). On the other hand, P. falciparum has been shown to stimulate HIV-1 replication through the production of cytokines (interleukin-6 and tumor necrosis factor-[alpha]) by activated lymphocytes (13). Plasmodium falciparum also increases the potential reservoir for HIV in the placenta by increasing the number of CCR5+ macrophages (14). An important study from Malawi showed that HIV-1 plasma viral loads were significantly higher in patients with malaria infection than in those without, and these levels remained higher for up to 10 weeks after treatment (15). The increases in viral load were highest in those with clinical malaria, high levels of parasitemia, and relatively high CD4 counts. Studies report that malaria may speed up the progression of HIV disease, and this is supported by a study from Uganda showing increased CD4 cell decline associated with episodes of malaria despite prompt treatment (11). However, the true clinical impact of malaria on HIV progression remains to be determined (16).

In areas of stable malaria, transmission is intense and continuous, although seasonal variations may occur. Immunity develops early in life, and young children and pregnant women are at greatest risk of morbidity and mortality from malaria. In these areas, HIV-related immunosuppression may increase rates of malaria infection and clinical malaria disease, but does not increase the rates of severe or complicated malaria (17). In regions of unstable malaria, transmission is intermittent and less predictable, and epidemics may occur. The disease burden is similar in all age groups because pre-existing anti malarial immunity is limited (18). Thus, HIV co-infection has its impact on disease presentation, with an increased risk of complicated and severe malaria and death (18). Studies of malaria and HIV interactions in children living in areas of stable malaria epidemiology have been inconclusive (19). A study in rural Kwazulu-Natal, an area of unstable malaria, reported that HIV-infected children were more likely to experience severe disease, coma, and death (20). More data are required to document any significant malaria and HIV interactions in children.

Malaria and HIV-1 are two of the most common infections in sub-Saharan Africa and, to a lesser extent, in other developing countries. An increased prevalence of malaria and increased parasite density in HIV-infected individuals could lead to increased malaria transmission affecting both HIV-positive and -negative individuals (17). The increased risk of clinical malaria in HIV-positive subjects could increase the burden on clinical services in areas where HIV-1 is prevalent as observed in the present western Indian study.

In a region with an increased HIV-1 prevalence of 30%, such as parts of southern Africa, the population-attributable fraction could reach 20% for parasitemia (10) and 35% for clinical malaria. However, malaria tends to affect mainly children, men and pregnant women, especially in rural areas, whereas HIV is more common among sexually active adults in urban centers.

Our findings suggest that HIV-1 infection is associated with malaria in hyperendemic areas. Further, the study suggests that the fraction of febrile illness attributable to malaria is lower in HIV positive adults. HIV testing should be conducted in malaria patients as an evaluation for febrile illness in malaria and HIV endemic areas.


(1.) Achidi EA, Salimonu LS, Asuzu MC, Berzin K, Walker O. Studies on Plasmodium falciparum parasitemia and development of anemia in Nigeria infants during their first year of life. Am J Trop Med Hyg 1996; 55: 132-3.

(2.) Alifrangis M, Lemage MM, Monn R, Theisen M. IgG reactives against recombinant rhoptry-associated protein-1 (Rrap-1) are associated with mixed Plasmodium infections and protection against disease in Tanzanian children. Parasitol 1999; 119: 337-42.

(3.) Goselle ON, Onwuliri COE, Onwuliri VA. Malaria infection in HIV/AIDS patients and its correlation with packed cell volume (PCV). J Vector Borne Dis 2009; 46: 205-11.

(4.) O'Callaghan-Gordo C, Bassat Q, Morais L, Diez-Padrisa N, Machevo S, Nhampossa T, Nhalungo D, Sanz S, Quinto L, Alonso PL, Roca A. Etiology and epidemiology of viral pneumonia among hospitalized children in rural Mozambique: a malaria endemic area with high prevalence of human immunodeficiency virus. Pediatr Infect Dis J 2011; 30(1): 39-44.

(5.) Morais L, Diez-Padrisa N, Machevo S, Nhampossa T, Nhalungo D, Sanz S, et al. Plaudisme grave et infection a VIH chez I'adulte a Bobo-Dioulasso, Burkina Fasco. Med Trop 2004; 64: 345-50.

(6.) Cohen C, Karstaedt A, Frean J, Thomas J, Govender N, Prentice E, Dini L, Galpin J, Crewe-Brown H. Increased prevelance of severe ON malaria in HIV-infected adults in South Africa. Clin Infect Dis 2005; 41: 1631-7.

(7.) Shah SN, Smith EE, Obonyo CO, Kain KC, Bloland PB, Sutsker L, Hamel MJ. HIV immunosuppression and antimalarial efficacy: sulfadoxine-pyrimethamine for the treatment of uncomplicated malaria in HIV-infected adults in Siaya, Kenya. J Infect Dis 2006; 194: 1519-28.

(8.) Birku Y, Mekonnen E, Bjorkman A, Wolday D. Delayed clearance of Plasmodium falciparum in patients with human immunodeficiency virus co-infection treated with artemisinin. Ethiop Med J 2002; 40(Suppl 1): 17-26.

(9.) Van Geentruyden JP, Mulenga M, Mwananyanda L, Chalwe V, Moerman F, Chilengi R, Kansongo W, VanOvermeir C, Dujardin JC, et al. HIV-1 immune suppression and antimalarial treatment outcome in Zambian adults with uncomplicated malaria. J Infect Dis 2006; 194: 917-25.

(10.) Abu-Raddad L, Patnaik P, Kublin JG. Dual infection with HIV and malaria fuels the spread of both diseases in sub-Saharan Africa. Science 2006; 314: 1603-6.

(11.) Tkachuk AN, Moormann AM, Poore JA, Rochtford RA, Chensue SW, Mwapasa V, et al. Malaria enhances expression of CC chemokine receptor 5 on placental macrophages. J Infect Dis 2001; 183: 967-72.

(12.) Malaria Fact Sheet No. 94. Geneva: World Health Organization. Available from: fs094/en/index.html

(13.) Good MF, Doolan DL. Immune effector mechanisms in malaria. Curr Opin Immunol 1999; 11: 412-9.

(14.) Moore JM, Ayisi J, Nahlen BL, Misore A, Lal AA, Udhayakumar V. Immunity to placental malaria II. Placental antigen-specific cytokine responses are impaired in human immunodeficiency virus-infected women. J Infect Dis 2000; 182: 960-4.

(15.) Froebel K, Howard W, Schafer JR, Howie F, Whitworth J, Kaleebu P, et al. Activation by malaria antigens renders mononuclear cells susceptible to HIV infection and re-activates replication of endogenous HIV in cells from HIV-infected adults. Parasite Immunol 2004; 26: 213-7.

(16.) Kublin JG, Patnaik P, Jere CS, Miller WC, Hoffman IF, Chimbiya N, et al. Effect of Plasmodium falciparum malaria on concentration of HIV-1-RNA in the blood of adults in rural Malawi: a prospective cohort study. Lancet 2005; 365: 233-40.

(17.) Brahmbhatt H, Kigozi G, Wabwire-Mangen F, Serwadda D, Sewankambo N, Lutalo T, et al. The effects of placental malaria on mother to child HIV transmission in Rakai, Uganda. AIDS 2003; 17: 2539-41.

(18.) Ned RM, Moore JM, Chaisavaneeyakorn S, Udhayakumar V. Modulation of immune responses during HIV-malaria co-infection in pregnancy. Trends Parasitol 2005; 21: 284-91.

(19.) Whitworth J, Morgan D, Quigley M, Smith A, Mayanja B, Eotu H, et al. Effect of HIV-1 and increasing immunosuppression on malaria parasitaemia and clinical episodes in adults in rural Uganda: a cohort study. Lancet 2000; 356: 1051-6.

(20.) Grimwade K, French N, Mbatha DD, Zungu DD, Dedicoat M, Gilks CF. HIV infection as a co-factor for severe falciparum malaria in adults living in a region of unstable malaria transmission in South Africa. AIDS 2004; 18: 547-54.

U. Shankarkumar, A. Shankarkumar & K. Ghosh

National Institute of Immunohaematology, KEM Hospital, Mumbai, India

Correspondence to: Dr U. Shankarkumar, Scientist 'D', National Institute of Immunohaematology, 13th Floor, KEM Hospital, Parel,

Mumbai-400 012, India.


Received: 9 February 2011 Accepted in revised form: 27 July 2011
Table 1. HIV testing in malaria patients and normal blood
bank donors from Mumbai, India

Patient           Malaria    Blood bank        OR      [X.sup.2]
status           patients    controls n
                 n = 171      = 28,749
                  (Pf% )        (Pf%)

Total HIV        7.60 (13)    1.81 (521)      4.45      28.331

Malaria & HIV
  co-infection   2.92 (5)       0 (0)        1899.4     680.12

Patient             EF          95% CI      P-value

Total HIV         0.0582      2.51-7.901    < 0.0001

Malaria & HIV
  co-infection    0.0291     104.53-34512   < 0.0001

Pf(%) phenotype frequency percentage; OR = Odds ratio;
EF = Etiological fraction; CI = 95% confidence interval.

Table 2. ELISA and western blot results of HIV-1
positive malaria patients

ID      First   Second   Western blot results
n=171   ELISA   ELISA
                          P17     P24     P31      gP41     P51

1       2.022   1.708     1+      3+      2+        2+      4+
2       0.497   0.055
3       2.496   1.642             4+      2+        1+      3+
4       0.558   0.129             1+
5       0.212   0.011     1+      1+
6       2.422   1.446     2+      4+      1+        3+      3+
7       1.721   1.453     1+      4+      2+        2+      4+
8       0.226   0.092     1+      1+
9       0.336   0.020     1+      2+
10      0.424   0.115     1+      2+
11      0.230   0.028             1+
12      2.171   1.264             2+      1+        1+      3+
13      0.321   0.040             4+

ID      Western blot results                     Remarks
         P55     P66     gP120   gP160   gP36    HIV-1

1        1+       3+      1+      1+             Positive
3        1+       3+      1+      1+             Positive
6                 3+      1+      1+             Positive
7        1+       4+      1+                     Positive
12       1+       3+      1+      1+             Positive

1+=Weak positive; 2+=Moderate positive; 3+ and 4+=Strong
positive; 8 out of 13 patients were first ELISA positive and
second one negative; 5 patients were both ELISA positive and
confirmed in western blot for HIV-1.
COPYRIGHT 2011 Indian Council of Medical Research
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2011 Gale, Cengage Learning. All rights reserved.

Article Details
Printer friendly Cite/link Email Feedback
Author:Shankarkumar, U.; Shankarkumar, A.; Ghosh, K.
Publication:Journal of Vector Borne Diseases
Article Type:Report
Geographic Code:9INDI
Date:Sep 1, 2011
Previous Article:Does electrocardiography at admission predict outcome in Crimean-Congo hemorrhagic fever?
Next Article:Species composition of Phlebotomine sandflies (Diptera: Psychodidae) in Nikshahr county, south-eastern Iran.

Terms of use | Privacy policy | Copyright © 2020 Farlex, Inc. | Feedback | For webmasters