Memorandum submitted by the Malaria Consortium
1. Malaria Consortium is an international
charity dedicated to improving the delivery of prevention and
treatment to combat malaria and other communicable disease in
Africa and Asia. We work with communities, health systems, government
and non-government agencies, academic institutions and local and
international organisations to ensure good evidence supports delivery
of effective services. More than 90% of our human and technical
resources are based in Africa and Asia supporting Ministries of
Health and partners in over twenty countries through our offices
in Uganda, Mozambique, Sudan, Southern Sudan, Zambia, Nigeria,
Ethiopia, Thailand and the UK.
2. Malaria Consortium welcomes the opportunity
to submit evidence to the International Development Select Committee's
inquiry on the Department for International Development's (DFID)
new AIDS strategy. Together with our partners in the South and
in Europe we have been investigating the interactions between
HIV/AIDS and malaria for some time and are pleased that one of
the things this inquiry is addressing is how HIV/AIDS interacts
with other diseases such as malaria.
3. In order to reduce the detrimental consequences
of dual infection with HIV and malaria, prevention and treatment
of the two diseases must mutually reinforce each other. There
is immense potential for synergies in particular at this time
of growing political and financial commitment to reduce the burden
of HIV/AIDS, malaria and tuberculosis.
4. Although we are pleased that DFID has
made supporting the integration of HIV and AIDS with malaria a
priority for action, we have the following concerns:
(a) The relationship between HIV and malaria
was not alluded to. The human cost of the epidemic of AIDS will
continue to be underestimated until the link with malaria is more
thoroughly acknowledged. Studies in recent years have highlighted
the interaction between malaria and HIV infection and revealed
HIV is playing a role in boosting adult malaria-infection rates.
(b) HIV/AIDS and malaria are also linked by geography,
extreme poverty and limited access to resources such as clinical
care and treatment. DFID need to acknowledge this more. People
living with HIV/AIDS who become infected with malaria are more
likely to develop severe manifestations of malaria such as anaemia
and cerebral malaria and are less responsive to malaria treatment
and at a higher risk of death from the disease. However it has
to be noted that this is only true for immuno-compromised AIDS
patients (CD4 count 200) and not for persons in the latent HIV
infection stage. The lowered immune response also contributes
to a reduced effectiveness of malaria treatment because this is
usually a result of both the medicine's effect and the immune
system's contribution. So in AIDS patients malaria parasite strains
with slightly reduced susceptibility will lead to treatment failure
when they would still be cleared in immuno-competent persons.
There is strong evidence for these relationships and they can
be assumed "proven".
(c) Specifically on page 34 there is mention
of the fact that HIV increases the risk of maternal death, for
example by exacerbating malaria and tuberculosis (TB) during pregnancy.
However DFID does not go on to explain how prevention and treatment
of all three diseases could be addressed through the platform
of maternal health services (especially antenatal clinic services).
It only talks about how the opportunity of integration of AIDS
services could be beneficial. Given there is increasing evidence
of a direct link between malaria and HIV with one disease making
the other worse and more difficult to treat, we feel DFID needs
to expand on this point. Pregnant HIV-positive women with placental
malaria infection are more likely to experience anaemia, adverse
birth outcomes such as pre-term birth and intrauterine growth
retardation, and deliver a low-birth-weight baby. Maternal Newborn
and Child Health (MNCH) services should include both prevention
of mother-to-child transmission (PMTCT) and malaria components
as they are important entry points for women into health services.
(d) On page 12, DFID say it is important to improve
rates of TB diagnosis among People Living with HIV/AIDS (PLWHA)
and to improve HIV diagnosis among people with TB. Again malaria
and HIV are neglected in terms of the possibilities of joint diagnostic
tools.
(e) On page 35, there is a mention of "stronger
links must also be forged between TB, malaria and HIV services".
The paragraph goes on to discuss TB but fails to mention malaria
again. We urge DFID to clarify and elaborate how they intent to
forge strong links between malaria and HIV as no where else in
this document is this mentioned.
5. RECOMMENDATIONS
We would suggest that several activities to
better integrate HIV and malaria could be undertaken but hasten
to add DFID makes no mention of them in this strategy:
(a) As stated already in the text malaria has
to be seen as one of the more common opportunistic infections
among AIDS patients in sub-Saharan Africa and malaria treatment
and prevention has to be part of any care package. The fact that
malaria control is moving to universal coverage helps as once
70-80% of the population are protected from malaria, PLWHA will
be included (knowingly or unknowingly).
(b) All AIDS patients with a CD4 count 200 should
receive weekly cotrimoxazole prophylaxis (cotrim is an antimalaria
and antibiotic shown to reduce a range of opportunistic infections)
as part of their treatment package.
(c) Protocols for preventive malaria treatment
in pregnancy (IPT) need to be adjusted to accommodate the fact
that women with HIV will need at least three doses of antimalarials
to have the same effect as in un-infected women. But also that
HIV+ women on cotrimoxazole should not receive IPT in addition.
(d) Voluntary Counselling and Testing (VCT) should
be offered to any adult patient with repeated febrile illnesses
(that is true for malaria but should cover all other febrile illnesses
also and as such is not a very specific integration but just good
practice of VCT).
6. We would like to see what Monitoring
and Evaluation framework DFID will put in place to measure the
strong links they are hoping to forge, in particular what indicators
they propose to monitor progress in terms of integrating malaria
and HIV services better.
7. We would like to see DFID make a firm
quantifiable commitment in terms of this integration and what
they wish to achieve rather than what seems to be at the moment
a broad aspiration lacking any concrete plans on how to achieve
it.
Submitted Autumn 2008
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