Anti-malarial effect of HIV protease inhibitors

Effect of antiretroviral therapy on malaria incidence in HIV-infected Ugandan adults.

Kasirye RP, Grosskurth H, Munderi P, Levin J, Anywaine Z, Nunn A, Kamali A, Baisley K. AIDS. 2017 Feb 20;31(4):577-582. doi: 10.1097/QAD.0000000000001344.

Introduction: Using the data of a trial on cotrimoxazole (CTX) cessation, we investigated the effect of different antiretroviral therapy (ART) regimens on the incidence of clinical malaria.

Methods: During the cotrimoxazole cessation trial (ISRCTN44723643), HIV-infected Ugandan adults with CD4 at least 250 cells/µl were randomized to receive either CTX prophylaxis or placebo and were followed for a median of 2.5 years. Blood slides for malaria microscopy were examined at scheduled visits and at unscheduled visits when the participant felt unwell. CD4 cell counts were done 6-monthly. Malaria was defined as fever with a positive blood slide. ART regimens were categorized as nucleoside reverse transcriptase inhibitor (NRTI) only, non-nucleoside reverse transcriptase inhibitor (NNRTI)-containing or protease inhibitor containing. Malaria incidence was calculated using random effects Poisson regression to account for clustering of events.

Results: Malaria incidence in the three ART regimen groups was 9.9 (3.6-27.4), 9.3 (8.3-10.4), and 3.5 (1.6-7.6) per 100 person-years, respectively. Incidence on protease inhibitors was lower than that on the other regimens with the results just reaching significance (adjusted rate ratio 0.4, 95% confidence interval = 0.2-1.0, comparing with NNRTI regimens). Stratification by CTX/placebo use gave similar results, without evidence of an interaction between the effects of CTX/placebo use and ART regimen. There was no evidence of an interaction between ART regimen and CD4 cell count.

Conclusion: There was some evidence that protease inhibitor-containing ART regimens may be associated with a lower clinical malaria incidence compared with other regimens. This effect was not modified by CTX use or CD4 cell count. The antimalarial properties of protease inhibitors may have clinical and public health importance.

Abstract [1]  Full-text [free] access  [2]

Editor’s notes: HIV protease inhibitors (PIs) have been shown to kill various life cycle stages of the malaria parasite both in vitro and in vivo at therapeutic drug levels.  A randomized controlled trial in children previously illustrated that PI-based antiretroviral therapy (ART) was associated with a lower risk of recurrent malaria compared to non-nucleoside reverse transcriptase inhibitor (NNRTI)-based ART.

This study is the first to present data illustrating a reduction in clinical malaria incidence in adults on a PI-based regimen. The authors used data from the COSTOP trial, which was originally designed to look at the safety of discontinuing trimethoprim-sulfamethoxazole (TMP-SMX, Septrin) in HIV-positive Ugandan adults with a CD4 cell count ≥250 cells/µL. A limitation is that only 4% of study participants were on a PI-based ART regimen, so numbers are small. In addition, the authors were unable to adjust for potential confounders relating to individual health status. However, this analysis is a useful addition to the evidence base, suggesting that PIs may have antimalarial properties of clinical and public health importance, especially settings with high malaria transmission and moderate to high HIV prevalence.

Comorbidity [4], HIV Treatment [5]
Africa [6]
Uganda [7]
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