Introduction
Malaria at the time of pregnancy can cause several adverse outcomes for both mother and newborn, including spontaneous abortions, stillbirths, restricted fetal growth, premature births, low birth weight, maternal anaemia and even leading to death of newborns in certain cases [1]. A meta-analysis conducted in 2022 revealed that, on average, 32.3% of pregnant women with HIV in the Sub-Saharan Africa region were affected by malaria [2]. Thus the integration of effective malaria prophylaxis strategies for HIV-infected pregnant women becomes critical due to the high prevalence and compounded health risks posed by both malaria and HIV [3].
In areas where malaria transmission is continuous, The World Health Organization advises the use of nets treated with insecticides and the intermittent administration of preventive treatment during pregnancy (IPTp) along with sulfadoxine-pyrimethamine (SP). This treatment should begin in the second trimester and be provided during antenatal care visits [4]. Additionally, in environments where bacterial infections or malaria are prevalent, as of now daily cotrimoxazole prophylaxis (CTX) is advised for pregnant women with HIV to prevent opportunistic infections [5]. The increasing resistance of the malaria parasite to CTX is compromising its effectiveness. In 2017, the World Health Organization stated that in regions with a high level of resistance, the daily unmonitored use of co-trimoxazole offered only limited protection against malaria for pregnant women who are HIV-positive. This underscores the need to explore new approaches to prevent malaria during pregnancy [6]. On the other hand, considering the use of Intermittent Preventive Treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP), which is typically administered to pregnant women without HIV, is not advisable for women on cotrimoxazole (CTX) prophylaxis. This is due to the potential risks associated with combining two similar types of antimicrobial drugs—antifolates and sulfonamides [7]. This creates a significant concern as women most vulnerable to malaria cannot use IPTp with SP, leaving them at high risk. To address these problems, many trials have been done to check how well malaria prophylaxis drugs work and their side effects in pregnant women with HIV who are on CTX prophylaxis. However very few strategies have come in recent years and most could not effectively and safely reduce the impact of malaria on this vulnerable population, enhancing health outcomes and influencing policy shifts in regions where malaria is endemic. Table 1 cites clinical trials on various malaria prevention strategies for pregnant women with HIV from 2012 to 2024. This article further delves deeper into significant trials that have produced reliable results.
Efficacy and Tolerability of Mefloquine (MQ) in HIV-Positive Pregnant Women
In a research study with a placebo group carried out in Kenya, Mozambique, and Tanzania, adding MQ to the daily CTX regimen for pregnant women significantly enhanced malaria protection and overall health of mothers. This was evident from the reduced number of hospital visits [8]. However, MQ was associated with increased risks of HIV transmission from mother to child and was generally poorly tolerated, with notable side effects such as dizziness and vomiting. Studies comparing IPTp treatments in four countries found that both MQ and SP had similar effects on low birth weight, but MQ was more effective in reducing parasitemia, anemia, clinical malaria, and outpatient visits, though it was less well-tolerated with higher instances of dizziness and vomiting [9]. The open-label design may affect the reliability of the safety assessments. The effectiveness of CTX alone versus MQ-IPTp showed that while CTX alone protected against malaria effectively, MQ-IPTp was superior in preventing placental infections [10]. In a study involving both HIV-positive and negative pregnant women, side effects like dizziness and vomiting were common with mefloquine IPTp; however, these adverse reactions occurred less frequently in HIV-infected participants. The likelihood of experiencing these side effects increased with factors such as a detectable viral load, initial dose of MQ, older age, and higher educational level. Despite these challenges, adherence to MQ IPTp remained high among the participants [11]. While MQ is more effective in preventing malaria compared to CTX, its adverse effects are concerning. Therefore, its application in HIV-positive pregnant women needs careful evaluation, with a focus on identifying safer options. Furthermore, the existing data doesn't provide a definite path for required modifications in policy.
Efficacy of Dihydroartemisinin-piperaquine (DP) in HIV-Positive Pregnant Women
Among many Dihydroartemisinin-piperaquine (DP) has stood out as one of the most promising