Challenges in the prevention, diagnosis, and treatment of malaria in human immunodeficiency virus-infected adults in sub-Saharan Africa

Background: Many countries in sub-Saharan Africa currently report high prevalences of both human immunodeficiency virus (HIV) and Plasmodium falciparum malaria. The likelihood of HIV-malaria coinfection may affect clinical management of patients. The extent to which standard clinical guidelines address HIV-malaria coinfection is unclear. Methods: We reviewed standard World Health Organization and other guidelines for diagnosis and treatment of malaria and/or HIV-related illness. We also searched PubMed ( 1990 to present) for literature on HIV-malaria interactions and treatment of coinfection. We restricted our review to the situation of the nonpregnant HIV-infected adult. Results: We found only 6 articles describing the clinical presentation of HIV-malaria coinfection in adults. We also identified 10 clinical or laboratory syndromes that are shared by malaria and AIDS-related conditions and that might provoke diagnostic confusion. We identified 12 antimalarial medications whose coadministration with antiretrovirals is known or suspected to result in drug-drug interactions or overlapping toxicities. Conclusions: Substantial overlap in the clinical and laboratory characteristics of malaria and HIV-related syndromes generates potential difficulties in AIDS staging and in diagnosis and management of patients at risk for coinfection. Significant drug-drug interactions and overlapping drug toxicity profiles further complicate concurrent management of malaria and HIV. Standard clinical guidelines do not reflect the full complexity of the interactions and overlaps between the 2 infections. Clinicians who manage HIV-infected patients in malaria-affected regions should systematically consider malaria when evaluating patients with a broad spectrum of symptoms. Further research is urgently needed to define best practices for prevention, diagnosis, and management of HIV-malaria coinfection in this region.