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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 3

Univariate sensitivity analyses of HIV-1 impact on malaria incidence and deaths, sub-Saharan Africa, 2004*

Scenario % increase in malaria incidence due to HIV (minimum and maximum)† % increase in malaria deaths due to HIV (minimum and maximum)†
Default scenario: see Tables 1 and 2. 1.3 (0.20–28)† 4.9 (0.65–114)†
Weaker effect of HIV-1 on malaria incidence: RR = 1.0 at CD4 >500/μL, RR = 2.0 at CD4 200–499/μL, and RR = 4.0 at CD4 <200/μL. 0.8 (0.11–16) 4.4 (0.60–90)
Stronger effect of HIV-1 on malaria incidence: RR = 1.5 at CD4 >500/μL, RR = 4.0 at CD4 200–499/μL, and RR = 8.0 at CD4 <200/μL. 2.2 (0.33–47) 5.7 (0.73–153)
Weaker effect of HIV-1 on malaria mortality (all groups): RR = 1.5 at CD4 >500/μL, RR = 2.0 at CD4 200–499/μL, and RR = 4.0 at CD4 <200/μL. n.a. 2.4 (0.30–59)‡
Weaker effect of HIV-1 on mortality in children <5 y in areas of high malaria transmission specifically, analogous to the comparatively weak effect of HIV-1 on incidence in this group: RR = 1.5 at CD4 >500/μL, RR = 2.0 at CD4 200–499/μL, and RR = 5.0 at CD4 <200/μL. n.a. 3.7 (0.45–114)
Stronger effect of HIV-1 on malaria mortality (all groups): RR = 3.0 at CD4 >500/μL, RR = 6.0 at CD4 200–499/μL, RR = 12.0 at CD4 <200/μL. n.a. 6.9 (0.92–157)§
Stronger decrease with age in malaria incidence: RRs compared to <5 y of 0.30 for 5–14y and 0.05 for >15 y in high malaria transmission areas, and 0.60 for 5–14 y and 0.10 for >15 y for areas of low and unstable malaria transmission including southern African countries. 1.0 (0.13–15) 4.0 (0.45– 59)
No decrease with age in malaria incidence at any malaria transmission intensity. 4.4 (0.54–37) 12.5 (1.5–153)
Stronger decrease with age in malaria CFR: 1.2% in <5 y at all malaria transmission intensities, 0.8% in >5 y at low and unstable transmission, 0.15% in >5 y at high transmission. n.a. 4.0 (0.53–107)
No decrease with age in malaria CFR at any transmission intensity. n.a. 5.7 (0.77–114)
HIV-1 increases malaria incidence also in children <5 y in areas of high malaria transmission. 2.0 (0.26–28) 5.9 (0.78–114)
CD4 count decline during HIV-1 infection: 1,000–100/μL¶ 1.0 (0.15–21) 3.7 (0.50–82)
CD4 count decline during HIV-1 infection: 700–0/μL# 1.7 (0.24–35) 6.2 (0.81–151)
No urban/rural difference in the malaria incidence rate 1.4 (0.20–28) 5.3 (0.67–114)
Lower HIV prevalence in adults: lower bound country estimates by UNAIDS/WHO** 0.9 (0.08–27) 3.2 (0.28–108)
Higher HIV prevalence in adults: upper bound country estimates by UNAIDS/WHO** 2.2 (0.37–29) 8.0 (1.2–121)
Lower HIV prevalence in children <14 y: lower bound country estimates by UNAIDS/WHO†† 1.3 (0.20–27) 3.9 (0.47–111)
Higher HIV prevalence in children <14 y: upper bound country estimates by UNAIDS/WHO†† 1.5 (0.23–29) 6.8 (1.08–119)

*N.A., not applicable; CFR, malaria case-fatality rate; RR, relative risk; UNAIDS, Joint United Nations Programme on HIV/AIDS/WHO.
†Continental total. In none of the scenarios did the ranking of countries in magnitude of HIV impact change appreciably. Across all scenarios, the minimum and maximum increases (in brackets) were always in Senegal or Mauritania, and in Botswana, respectively. An exception was the scenarios of lower HIV prevalence in adults, for which the lowest malaria impacts would be in Sierra Leone and Somalia.
‡The overall relative risk for malaria mortality due to HIV-1 in stable HIV-1 epidemics is now 2.1, i.e., does no longer fit the observed value of ≈4 (see Methods, Malaria mortality and Effect of HIV).
§The overall relative risk for malaria mortality due to HIV-1 in stable HIV-1 epidemics is now 5.7, i.e., does no longer fit the observed value of ≈4 (see Methods, Malaria death and effect of HIV).
¶As in Western populations (25).
#To allow for a possible initial drop in CD4 immediately upon infection, i.e., still before seroconversion.
**Cross-country median lowerbound estimate of HIV prevalence in adults 2.7%; cross-country median upperbound HIV prevalence estimate 8.8% (compared to default point estimate of 4.8%).
††Cross-country median lowerbound estimate of HIV prevalence in children <14 years of 0.2%; cross-country median upperbound HIV prevalence estimate 1.1% (compared to default point estimate of 0.5%).

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