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Volume 11, Number 9—September 2005

Research

Malaria Attributable to the HIV-1 Epidemic, Sub-Saharan Africa

Eline L. Korenromp*†Comments to Author , Brian G. Williams*, Sake J. de Vlas†, Eleanor Gouws‡, Charles F. Gilks*, Peter D. Ghys‡, and Bernard L. Nahlen*
Author affiliations: *World Health Organization, Geneva, Switzerland; †Erasmus University Medical Center, Rotterdam, the Netherlands; ‡Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland

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Table 1

HIV-1, malaria incidence and death rates. and their interactions*

Parameter Assumption
Malaria transmission intensity Index >0 and <0.75 denotes low-intensity transmission and >0.75 denotes high-intensity transmission, except for southern Africa, where index >0.75 denotes unstable transmission (18,19)
Overall malaria incidence Middle Africa, high-transmission areas: 1.4 per person per year in children <5 y, 0.59 per person per year at 5–14 y, 0.11 per person per year at >15 y (19)
Middle Africa, low-transmission areas: 0.182 per person per year in children <15 y, 0.091 per person per year at >15 y (19)
Southern Africa: 0.0294 per person per year as all-age average in areas with (unstable) malaria transmission; divided as twice the rate at >15 y compared to <14 y (19)
Relative malaria incidence urban/rural 0.50 (20)
Malaria deaths High-transmission areas: 0.8% of incident cases in children <5 y, 0.3% at >5 y;
Low-transmission and unstable transmission areas: 0.8% of incident cases in all age groups (21).
Effect of HIV-1 on incidence of clinical malaria >5 years in areas with high-intensity malaria transmission, and all age groups in areas with low-intensity or unstable malaria transmission:
CD4 >500/μL RR = 1.2
CD4 200–499/μL RR = 3.0
CD4 <200/μL RR = 5.0†
<5 years in high-transmission areas: no effect
Effect of HIV-1 on malaria case fatality rate All malaria transmission intensities and age groups:
CD4 >500/μL RR = 2.0
CD4 200–499/μL RR = 4.0
CD4 <200/μL RR = 10‡
Survival after HIV-1 infection Median 9 years, following a Weibull curve with shape parameter 2.28 (22)
CD4 decline over the course of HIV-1 infection Linear from 825/μL at seroconversion to 20/μL at death of AIDS (2326)

*RR = relative risk associated with HIV-1 infection; y = years of age.
†From (9,10). Earlier studies did not consistently show these effects, but these were cross-sectional and/or hospital-based (1). Effects of HIV-1 in these studies may have been obscured by a lack of adjustment for prestudy treatment with antimalarial drugs (which might be more common in HIV-1 patients with recurrent fevers [27]) and by their inherent dependence on the relative survival of HIV-infected and HIV-uninfected participants, given the increased case fatality of malaria among HIV-infected patients (6). At the specified CD4-stratum-specific relative risks, the relative risk averaged over all HIV-infected people would be 2.1 in Madagascar and 2.5 in all other countries (see Methods, CD4 distributions among HIV-infected people).
‡At these CD4-stratum-specific relative risks, the relative risk averaged over all HIV-infected people would be 3.4 in Madagascar and 4.1 in all other countries (see Methods, CD4 distributions among HIV-infected people).

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