HIV infection and malaria in pregnancy in western Kenya. Their interaction and effects on maternal and infant health Ayisi, J.G.

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1 UvA-DARE (Digitl Acdemic Repository) HIV infection nd mlri in pregnncy in western Keny. Their interction nd effects on mternl nd infnt helth Ayisi, J.G. Link to publiction Cittion for published version (APA): Ayisi, J. G. (2002). HIV infection nd mlri in pregnncy in western Keny. Their interction nd effects on mternl nd infnt helth s.l.: s.n. Generl rights It is not permitted to downlod or to forwrd/distribute the text or prt of it without the consent of the uthor(s) nd/or copyright holder(s), other thn for strictly personl, individul use, unless the work is under n open content license (like Cretive Commons). Disclimer/Complints regultions If you believe tht digitl publiction of certin mteril infringes ny of your rights or (privcy) interests, plese let the Librry know, stting your resons. In cse of legitimte complint, the Librry will mke the mteril inccessible nd/or remove it from the website. Plese Ask the Librry: or letter to: Librry of the University of Amsterdm, Secretrit, Singel 425, 1012 WP Amsterdm, The Netherlnds. You will be contcted s soon s possible. UvA-DARE is service provided by the librry of the University of Amsterdm ( Downlod dte: 25 Nov 2018

2 The effect of dul infection with HIV nd mlri on pregnncy outcome in western Keny 1 Submitted

3 2 The effect of dul infection with HIV nd mlri on pregnncy outcome in western Keny John G. Ayisi MSc*\ Ann M. vn Eijk MD**, Feiko O. ter Kuile MD, PhD*,, Mrgrette S. Kolczk PhD, Julin A. Otieno MMED f, Ambrose O. Misore MMED f, Piet A. Kger MD, PhD', Richrd W. Steketee MD, MPH, Bernrd L. Nhlen MD J. Author's Affilitions: Centre for Vector Biology & Control Reserch, Keny Medicl Reserch Institute, Kisumu, Keny; deprtment of Infectious Diseses, Tropicl Medicine & AIDS, Acdemic Medicl Centre, University of Amsterdm, Amsterdm, The Netherlnds; ^Division of Prsitic Diseses, NCTD, CDC, Atlnt, GA, USA; Ministry of Helth, Kisumu, Keny; *Roll Bck Mlri, World Helth Orgniztion, Genev, Switzerlnd. Running Hed: HIV, Mlri, nd pregnncy outcome in western Keny Sponsorship: Supported by the United Sttes Agency for Interntionl Development (USABD) nd The Netherlnds Foundtion for the Advncement of Tropicl Reserch (WOTRO), The Hgue, The Netherlnds. Correspondence to: John G. Ayisi, Centre for Vector Biology & Control Reserch, Keny Medicl Reserch Institute, P.O. Box 1578, Kisumu, Keny. Tel: (+254) Fx: (+254) Emil JAyisi(o>kisin.mimcom.net Disclimer: Use of trde nmes is for identifiction only nd does not imply endorsement by the Keny Medicl Reserch Institute or The Ministry of Helth, Keny or by the Public Helth Service, US Deprtment of Helth nd Humn Services.

4 Objective: 3 To determine the effect of dul infection with HIV nd mlri on birth outcome nd mternl nemi mong women delivering t lrge public hospitl in Kisumu, western Keny. Subjects nd methods: Dt on obstetricl nd neontl chrcteristics, mternl nd plcentl prsitemi, nd postprtum hemoglobin (Hb) were collected mong ll women enrolled in cohort study of the interction between mlri nd HIV during pregnncy. Results: Between dt were vilble from 2466 singleton deliveries. The mternl HIV seroprevlence ws 24.3%, nd t delivery 22.0% of the women hd evidence of mlri. Low birthweight (LBW), preterm delivery (PTD), intruterine growth retrdtion (IUGR) nd mternl nemi (Hb<8 g/dl) occurred in 4.6%, 6.7%, 9.8% nd 13.8% of deliveries respectively. Mternl HTV, in the bsence of mlri, ws ssocited with 99 g (95% CI ) reduction in men birthweight mong ll grvide. Mlri ws ssocited with both IUGR nd PTD, resulting in reduction in men (95% CI) birthweight of 145g (82-209) mong HIV-seronegtive nd 206g ( ) mong HIV-seropositive primigrvide, but not mong multigrvide. Both HTV nd mlri were significnt risk fctors for postprtum mternl nemi, nd HIV-seropositive women with mlri were twice s likely to hve Hb < 8g/dl thn HIV-seronegtive women with or without mlri. Conclusion: Women with dul infection re t prticulr risk of dverse birth outcome. In res with moderte or high prevlence of HIV nd mlri, ll pregnnt women should be the focus for mlri nd nemi control efforts to improve birth outcomes. Keywords: Low birth weight, preterm delivery, intruterine growth retrdtion, HIV, mlri, Keny.

5 Introduction 4 Mlri during pregnncy is mjor problem in sub-shrn Afric, ffecting n estimted 24 million pregnnt women ech yer [1,2]. In mlri endemic res Plsmodium flciprum prsitemi during pregnncy is ssocited with nemi in pregnnt women, nd low birthweight (LBW) resulting from premture delivery nd intruterine growth retrdtion [3-5], nd LBW is n importnt risk fctors for erly infnt mortlity nd morbidity [6]. During the pst two decdes, HIV/AIDS hs emerged s mjor problem in mny mlri-endemic res of sub-shrn Afric where n estimted 28 million people re infected with HIV [7]. Afric south of the Shr ccounts for over two-thirds of the world's 40 million HIV-infected persons, nd 80% of the world's HIV-infected women [7], with HIV prevlence s high s 25-45% mong pregnnt women [7-14]. Given the wide geogrphicl overlp between HIV nd mlri, the epidemic of HIV/AIDS in res where P. flciprum is endemic hs generted serious concern bout potentil interctions between the two infections [9,11,13,14,15]. Studies mong pregnnt women in sub-shrn Afric hve shown tht HIV-infected women, prticulrly multigrvide re more likely to be infected with P. flciprum, nd to hve higher prsite densities thn HIV uninfected women [9,11,13]. Thus, HIV infection seems to lter the well estblished prity-specific pttern of mlri susceptibility in res of stble mlri trnsmission, where in the bsence of HTV, primigrvide nd, to lesser extent, secundigrvide re more ffected thn re other prities [1,3]. Although it is now well estblished tht HIV-infected pregnnt women re more susceptible to mlri, little is known of the dverse consequences of dul infection with mternl HIV nd mlri on pregnncy outcome. We report here the effects of dul infections on infnt outcomes, including their effect on the two mjor etiologicl pthwys of

6 LBW: shortened gesttion [preterm delivery (PTD)] nd intruterine growth retrdtion 5 (IUGR) [i.e., smll for gesttionl ge (SGA)] [17]. Becuse mternl mlri nd HIV infections re lso ssocited with n increse in severity of nemi, known risk fctor for mternl deth nd poor infnt outcomes [18-21], we lso report on the effect of dul infections on mternl nemi t delivery. Subjects nd methods Study site This study ws conducted t the Nynz Provincil Generl Hospitl (NPGH) in Kisumu, city with popultion of pproximtely people, locted on the shores of Lke Victori. Mlri trnsmission is perennil nd P. flciprum ccounts for 98% of the mlri cses, the remining 2.0% being cused by P. mlrie nd P. ovle. Chloroquine resistnce is widespred with 75-80% of P. flciprum strins showing RH/RHI resistnce [22]. NPGH is 400-bed government referrl hospitl providing helth cre mostly to the locl low-income popultion. On verge, bout 100 pregnnt women present ech dy to the ntentl cre (ANC) clinic, 30 of whom do so for their first visit. As prt of the ANC pckge for this hospitl, women re tested for syphilis using the rpid plsm regin (RPR) crd test, (Becton Dickinson microbiologicl systems, Cockeyville, USA), nd those serorective for syphilis re treted with 2.4mU intrmsculr benzthine penicillin [23]. The study ws completed before the introduction of intermittent protective tretment with sulfdoxine-pyrimethmine s the ntionl policy for control of mlri in pregnncy [11]. Enrollment Procedures Enrollemnt procedures hve been described elsewhere [24]. Briefly, helthy pregnnt women with no known underlying disese visiting the prentl clinic service of the NPGH

7 with n uncomplicted singleton pregnncy of t lest 32 weeks gesttion nd residing in 6 Kisumu re were invited to prticipte. After informed consent ws obtined, questionnire ws completed to collect informtion on socioeconomic sttus, medicl, nd obstetricl history, nd body weight ws mesured. After the client received counseling bout HIV, blood ws obtined by finger prick for HIV testing, mlri thick smer nd hemoglobin levels. Post-test counseling, supportive counseling nd hemtinics were offered to ll prticipting women, nd women with symptomtic mlri were treted. All screened women were encourged to deliver in NPGH. At delivery, blood ws gin obtined from the mother for mlri smer nd hemoglobin, nd plcentl blood smer ws obtined. Within 24 hours of birth, infnts were weighed on n electronic blnce (Ohus Florhm Prk, NJ, USA), nd their gesttionl ge ws ssessed by trined study ssistnts using the modified Dubowitz method [25]. Ethicl review The study protocol ws pproved by the institutionl review bords of the Keny Medicl Reserch Institute (KEMRI), the Centers for Disese Control nd Prevention (CDC), Atlnt, Georgi (USA) nd the Acdemic Medicl Center (AMC), University of Amsterdm, Amsterdm, The Netherlnds. Lbortory Procedures Peripherl nd plcentl blood smers were stined with Giems nd exmined for mlri prsites. A thick smer ws considered negtive if 100 microscopic fields reveled no prsites. Hemoglobin ws mesured using Hemocue (Mission Viejo, CA, USA.). HTV testing involved two rpid tests: n initil Serostrip HIV-1/2 (Sliv Dignostic Systems Pte. Ltd, Singpore ) nd confirmtory Cpillus HIV-l/HiV-2

8 (Cmbridge Dignostics, Wicklow, Irelnd Ltd) on smples tht tested positive. Western 7 blot ws performed on discordnt smples. Definitions An uncomplicted pregnncy ws defined s pregnncy without the presence of hypertension, pre-eclmpsi, polyhydrmnios, n bnorml presenttion of the foetus, history of previous cesren section, hemorrhge, or repeted spontneous bortions (>2). Becuse we were interested in the overll effect of mlri in pregnncy, mlri infection t delivery ws defined s ny evidence of current mlril infection (post-delivery mternl peripherl prsitemi or plcentl prsitemi, either in the presence of sexul stges or mlri pigment), detected on thick blood smer. Hemoglobin (Hb) < 1 lg/dl of blood nd <8g/dl were considered nemi nd moderte to severe nemi, respectively [26,27]. HIVseropositivity ws defined s positive result on both rpid tests; women not rective with the initil Serostrip HIV-1/2 test were considered HIV-seronegtive. Women who were HIVseronegtive nd hd no mlri t delivery were considered to be uninfected. Women who were HIV-seronegtive but hd mlri t delivery were considered to be infected with mlri-lone. Women who were HTV-seropositive but hd no mlri t delivery were considered to be infected with HIV-lqne. Women were considered to hve dul infection if they were HIV-seropositive nd hd mlri t delivery. Newborns were clssified s low birthweight (LBW) if they weighed <2500g [28]. Preterm delivery (PTD) ws defined s ny delivery tht occurred before 37 completed weeks of gesttion. Smll for gesttionl ge (SGA) ws defined s sex-specific birthweight t or below the 10 th percentile for weightfor-gesttionl ge of n interntionl reference popultion [29]. For the purpose of this nlysis norml weight-for-gesttionl ge were children with birthweights >10 th percentile

9 of the weight-for-gesttionl ge reference popultion. Riny seson included the months of April, My nd June (long rins) nd October nd November (short rins). Dt nlysis nd sttisticl methods Differences in mens were compred using the Student t test, nd differences in proportions were nlyzed using the chi-squre test. Risk rtios (RR) were computed with 95% confidence intervls (CI) to mesure the strength of the ssocitions. The reltionship between mlri t delivery, mternl HIV infection nd demogrphic nd obstetric fctors on dverse birth outcome (defined s LBW, PTD or SGA infnt, or moderte to severe mternl nemi t delivery) were investigted by bivrite nlysis, strtified by grvidity (primigrvide versus multigrvide). Adjusted risk rtios were computed using Poisson logliner model of grouped dt, with ech person in the group ssumed to hve the sme time t risk [30-33]; models were djusted for mternl weight (< 25 percentile versus >25 percentile, kg), mternl ge (< 20 versus >20 yers), yers of eduction (< 8 versus >8 yers), ethnicity (Luo versus non Luo), seson of delivery (riny versus dry), hospitliztion in current pregnncy, nd gender of the child. The models for postprtum nemi were lso djusted for type of delivery (cesren section or ssisted delivery versus norml delivery) nd use of hemtinics. The covrites were included in the models if they were significntly ssocited with ny of the four outcomes mesures in the bivrite nlyses, or if they were known to be ssocited with these outcomes bsed on prior studies. Multiple liner model [34] ws used to ssess the effect of HIV, mlri, nd dul infection on birth weight, gesttionl ge nd mternl hemoglobin. We ssessed interction between mlri nd HIV in seprte models, but no sttisticlly significnt interction ws evident. We then repeted the nlyses using the infection ctegories: no infection, HlV-lone, mlri lone or dul infection. Anlysis ws done using EPI INFO 6.01 (Centers for Disese Control nd

10 Prevention, Atlnt, GA, USA) nd SAS (Version 6.12, SAS Institute, Cry, North 9 Crolin, USA). Results Study popultion Between June 1996 nd Mrch 1999, 5,168 women were screened of whom 75 (1.5%) did not hve complete lbortory results. Of the remining 5093 women, nd consistent with ptterns of home versus helth fcility delivery, 2539 (49.9%) delivered t the study hospitl (Figure 1). Women with twins (36), nd women without mlri result (37) were excluded from nlysis (Figure 1). Compred to women who were included in the nlysis, those who were excluded (i.e., home delivery or incomplete lbortory dt) were more likely to be older, to hve < 8 yers of eduction, to be mrried, to be multigrvide, to be of Luo ethnicity, to reside in the peri-urbn rther thn urbn re of Kisumu, nd to hve moderte-to-severe nemi in the third trimester. Prevlence of HIV, syphilis nd mlri in the third trimester ws similr between the two groups (dt not shown). Of the 2466 women included in the nlysis, 1169 (47.4%) were primigrvide. Compred to multigrvide, primigrvide women were more likely to be younger [men ge, stndrd devition (SD) 18.8 (2.5) versus 24.3 (4.7) yers; PO.OOl]. Among the 2466 women, 599 (24.3%) were HIV-seropositive nd 543 (22.0%) hd evidence of mlri infection t delivery. Mlri infection t delivery occurred in 179 of 599 HIVseropositive women (29.9%) compred to 364 of 1867 HIV-seronegtive women (19.5%) [risk rtio (RR), 1.5; 95% Confidence Intervl (CI), ; P < 0.001], nd ws more common mong primigrvide in whom 323 out of 1169 (27.6%) hd mlri t delivery compred to 220 out of 1297 (17.0%) mong multigrvide (RR, 1.6; 95% CI, ; P

11 < 0.001). Compring women who hd nd who did hve mlri t delivery, women who 10 hd mlri t delivery were more likely to hve hd mlri in the third trimester 45.1% (245 out of 543) versus 11.8% (227 out of 1923), (RR, 3.8; 95% CI, , P< 0.001). Of the 34 stillbirths, 17(1.1%) were recorded mong 1503 women without HIV nd mlri infection, 4 (1.0%) mong 420 women infected with HIV-lone, 9 (2.5%) mong 364 women with mlri-lone, nd 4 (2.2%) mong 179 women with dul infection. Compred to women without mlri, stillbirths were more common in women with mlri infection t delivery, irrespective of HIV sttus [ 1.1 % (21 of 1923) versus 2.4% (13 of 543); P = 0.02]; stillbirth rtes were similr in women with nd without HIV infection regrdless of mlri infection sttus [1.3% (8 of 599) versus 1.4% (26 of 1867); P = 1.00]. Becuse of the smll numbers, ll stillborn infnts were removed from the further nlysis, leving 2432 live singleton infnts with mternl HTV nd mlril infection sttus vilble for nlysis (Figure 1). Cigrette smoking, wellknown risk fctor for low birthweight, ws not common in this popultion (reported by less thn 1% of the women) nd ws not included in the nlysis. Chrcteristics of the women studied strtified by outcome t delivery re shown in Tble 1. Third trimester nemi, HIV infection, mlri t delivery nd dul infection hd the strongest ssocition with n dverse birth outcome. Birth weight: Birthweight ws recorded for 2431 infnts (99.9%). The overll men (SD) birthweight ws 3235 g (450), nd 113 of 2431 bbies (4.6%) hd LBW. An increse in LBW prevlence ws seen mong firstborns of mothers with HIV-lone, mlri-lone, or dul infection compred to those with neither infection (P = 0.09, nd O.001, respectively) (Tble 2). However, no difference ws seen in prevlence of low

12 11 birthweight nd mternl infection sttus mong multigrvide (P = 0.3, P = 0.4, nd P = 1.0, respectively). Women who hd prsitemi in the third trimester nd lso hd mlri t delivery were t higher risk of delivering LBW bby compred to prsitemic women in the third trimester who hd mlri t delivery [10.5 % (25 out of 239) versus 5.5% (16 out of 291), RR, 1.9; 95% C, ; P = 0.04]. In Poisson model mong the primigrvide, mlri-lone nd dul infection were ssocited with 2-fold nd 3-fold incresed risk of LBW (P = nd P < 0.001) respectively, with no significnt effect seen in women with similr sttus mong the multigrvide (P=0.7 for both groups; Tble 3). In liner model, mternl HIV infection ws ssocited with 99 g (95% CI, ) reduction in men birthweight mong ll grvide (P < 0.001). Among primigrvide, the men (SD) birthweight of infnts of uninfected women ws 3186 g (416) (Figure 2). After djusting for other covrites in the liner model, this men (95% CI) birthweight ws 40g (-32 to 112; P = 0.3) lower in primigrvide women with HIVlone, 145 g (82-209; P = 0.001) lower in primigrvide women with mlri-lone, nd 206 g ( ; P = 0.001) lower in primigrvide with dul infection. The men (SD) birthweight of infnts of uninfected multigrvide women ws 3373g (447). Mternl HlV-lone nd dul infection lowered this men birthweight by 138g (78-199) nd 161g (63-259), respectively (P < for ech), but mlri infection lone hd no effect (8g, 95% CI-71 to 88; P = 0.80). Gesttionl ge: Gesttionl ge ws determined for 2397 infnts (98.6%). The men (SD) gesttionl ge ws 38.6 weeks (1.3 weeks) nd 160 infnts (6.7%) were PTD. Higher rtes of preterm

13 delivery were seen with mternl mlri infection (P = 0.027) or dul HIV/mlri 12 infection (P < ), but only in the primigrvide (Tble 2). In Poisson model, primigrvide women infected with mlri-lone hd incresed risk of PTD when compred with uninfected women, but this risk ws only mrginlly significnt (ƒ> = 0.06), while dul-infection in the sme group incresed the risk of PTD by 3- fold (P < 0.001); none of the infections hd ny effect on PTD mong the multigrvide (fflv-lone P = 0.5, mlri-lone P = 0.3 nd dul-infection P = 0.2, Tble 3). The men (SD) gesttionl ge of infnts of uninfected primigrvide women ws 38.6 (1.3) weeks. In liner model, mlri nd dul infection hd miniml, but significnt effect on men gesttionl ge mong primigrvide, but not mong multigrvide (dt not shown). Smll for gesttionl ge: Overll, the prevlence of smll-for-gesttionl ge (SGA) ws 9.8% (236 out of 2397) nd like PTD, the prevlence of SGA ws higher mong primigrvide with mlri-lone (P = 0.008) or primigrvide nd multigrvide with dul-infection (ƒ> = 0.02), nd (P = 0.01) respectively (Tble 2). Women who hd prsitemi in the third trimester nd lso t delivery were t higher risk of delivery of SGA infnt compred to prsitemic women in the third trimester who hd mlri t delivery [18.2% (43 out of 2h6) versus 11.4% (33 out of 290), RR, 1.6; 95% CI, ; P = 0.03], but no effect ws observed on premturity [8.5% (20 out of 236) versus 9.0% (26 out of 290), RR, 0.9; 95% CI, ; P=0.8]. In Poisson model, primigrvide women infected with mlri-lone (P = 0.01) or dul infection (P = 0.03) were t incresed risk of delivery of SGA infnt when compred with uninfected women (Tble 3). Multigrvide with dul infection hd borderline significnt increse in the risk of SGA (P = 0.06).

14 Mternl nemi: 13 A hemoglobin ws vilble for 2173 women (89.4%). The men (SD) hemoglobin ws 10.5 (2.4) g/dl nd 1243 out of 2173 women (57.2%) hd nemi (Hb < 11 g/dl), nd 300 women (13.8%) hd moderte to severe nemi (Hb < 8 g/dl). A higher prevlence of moderte to severe nemi ws seen mong primigrvide with HIV-lone (P = 0.008) nd in both grvide with dul infection (P = for primigrvide) nd (P < for multigrvide) (Tble 2). In Poisson model, primigrvide with HIV-lone hd 1.8-fold incresed risk of postprtum moderte to severe nemi (P = 0.01; Tble 3), nd this risk ws more thn 2-fold mong dully infected primigrvide or multigrvide (P = nd P < respectively). Men hemoglobin levels, strtified by mternl infection sttus nd grvidity re shown in Figure 3. The men (SD) hemoglobin of uninfected primigrvide ws 10.8 (2.4) g/dl. After djusting for other covrites in the multiple liner model, this men (95% CI) hemoglobin ws 0.9 ( ) g/dl lower in primigrvide women with HTVlone (P< 0.001), 0.8 ( ) g/dl lower in primigrvide women with mlri-lone (P < 0.001), nd 1.5 ( ) g/dl lower in women with dul infection (P < 0.001) (Figure 3). Among uninfected multigrvide women, the men (SD) hemoglobin ws 10.7 (2.4) g/dl. Multiple liner model mong multigrvide women, showed tht infection with HIV-lone lowered the men (95% CI) Hb levels by 0.4 ( ) g/dl (P = 0.03), but mlri-lone hd no effect, men reduction 0.4 ( ) (P = 0.1). Dul infection significntly lowered the men (95% CI) Hb by 1.3 ( ) g/dl (P< 0.001) (Figure 3). Adverse birth outcome in reltion to single versus dul infection Compred to primigrvide women infected with HIV-lone, those with dul infection hd mrginlly incresed risk of delivery of LBW bby (P = 0.06) nd

15 significntly incresed the risk of PTD (P = 0.03); nd, nemi {P = 0.002) mong the 14 multigrvide (Tble 3). Similrly, dul infection incresed the risk of mternl nemi mong the primigrvide (P = 0.05) nd multigrvide {P = 0.03) over nd bove the risk due to infection with mlri-lone (Tble 3). Discussion Compred to uninfected women (with no mlri or HIV), mternl HIV infection ws ssocited with 99 g reduction in men birthweigh, which is consistent with findings of other studies in the region [35,36]. This effect ws gretest mong the multigrvide (138 g), lthough this reduction did not trnslte into greter risk of LBW. Neither PTD nor SGA ws ssocited with HTV-infection lone, finding consistent with Ugndn study mong symptomtic HIV-seropositive women [35], but in contrst to findings from Kinshs, Zire [37]. The ltter study included women with symptomtic HIV-infection nd significntly higher prevlence of PTD nd LBW ws reported mong infnts in tht study [37]. Infection with HIV-lone nerly doubled the risk of postprtum moderte to severe nemi in primigrvide, nd ws ssocited with reduction in men hemoglobin levels in multigrvide, nd is consistent with previous report [21]. Postprtum hemorrhge hs been found to be ssocited with HIV infection [38] nd could hve lowered the postprtum Hb levels in our study, however, this pregnncy outcome ws reported in less thn 1% of our study popultion nd could not be further evluted in our study. In ddition, time between delivery nd tking blood for Hb could ffect the mternl postprtum Hb levels due to volume redistribution resulting from the effects of lbour. However, blood smple for Hb estimtion in our study ws tken soon fter delivery in consistent mnner for ll the women in the four groups. Thus the

16 observed trend in Figure 3 is likely true trend reflecting the direct effect of HIV [39] 15 nd/or its co-infection with mlri on postprtum nemi. As expected, mternl mlri infection identified t delivery ws ssocited with reduction in men birth weight resulting from combintion of reduced gesttionl ge nd n incresed risk of intruterine growth retrdtion mong the primigrvide [40]. Women who hd prsitemi during the third trimester nd lso hd mlri t delivery hd incresed risk of both LBW nd SGA, when compred to women with mlri t delivery but hd no detectble prsitemi in third trimester. This my reflect the effect of chronic mlri infection on foetl growth. When compred to uninfected women, dul infection mong primigrvide ws ssocited with 3-fold incresed risk of LBW, lmost 3-fold incresed risk of premturity, nd bout 2-fold incresed risk of SGA. In ddition, dul infection more thn doubled the risk of moderte to severe nemi (Hb < 8 g/dl) in both primigrvide nd multigrvide. Comprison of dully infected women with women infected with HIV-lone showed tht the risks of LBW nd premturity mong primigrvide, nd moderte to severe nemi mong the multigrvide were excerbted by co-existent mlri. Similrly, when compred to women infected with mlri-lone, dul infection substntilly incresed the risk of moderte to severe nemi over nd bove tht mong primigrvide nd multigrvide women infected with mlri-lone. We re currently lso investigting whether children born from women dully infected with HIV nd plcentl mlri re more likely to be infected with HIV, due to incresed trnsmission of HIV from mother to infnt in the presence of plcentl infections with P. flciprum s ws postulted in study from Mlwi [41]. Our study hs severl limittions nd my not be fully generlizble to other popultions. In our study popultion, only 4.6% of the infnts hd LBW, compred to

17 15.0% reported by previous study from the sme hospitl [42]. This is likely to hve 16 resulted from the different entry criteri used in the current study: s opposed to the previous study tht included ll women ttending delivery t our study hospitl, women in the current study were eligible for screening only if they hd no known underlying disese nd, hd ttined gesttionl ge of 32 weeks or more, nd hd n uncomplicted pregnncy. Therefore, our study smple is not representtive of the overll ANC popultion in this hospitl nd represents selection of otherwise "helthy" women. Becuse of our study design, we only collected dt on women who hd met the inclusion criteri, nd no pre-enrollment dt ws documented t the recruitment stge on women who were not eligible for enrollment. Becuse we only included women with gesttionl ge > 32 weeks, the effects of HIV nd mlri infection on erly events of pregnncy outcome, such s bortions, nd very premture delivery could not be evluted. In ddition, the number of perintl deths in our study ws smll (2.0% n = 2466), likely due to the sme resons noted bove. Our study demonstrtes tht women with dul infection re t prticulr risk of dverse birth outcome. In res with moderte or high prevlence of HIV nd mlri, ll pregnnt women should be the focus for mlri control efforts to improve birth outcomes. It is importnt to ssess if tretments of nemi tht hve proven to be beneficil in HTVseronegtive pregnnt women offer the sme benefits in HTV-seropositive women.

18 Acknowledgements 17 This study ws supported by grnt number AOT0483-PH1-2171, HRN-A from the United Sttes Agency for Interntionl Development (USATD). John G. Ayisi, Drs. Ann Mri vn Eijk nd Feiko O. ter Kuile were supported by The Netherlnds Foundtion for the Advncement of Tropicl Reserch (WOTRO), The Hgue, The Netherlnds. We would like to thnk the project stff t the ANC, lbour wrd, counsellors, lbortory technicins nd computer dt entry stff for ssisting in mny wys to relize this work. We thnk Dr. Kevin DeCock for his vluble comments on the mnuscript. We lso thnk Dr. John Odondi, the Medicl Superintendent, nd helth workers from the Nynz Provincil Generl Hospitl for their coopertion in the study. Our specil thnks go to ll the pregnnt women who prticipted in this study, nd the Director of the Keny Medicl Reserch Institute (KEMRI) for his permission to publish this work.

19 1. McGregor IA: Epidemiology, Mlri nd Pregnncy. Am J Trop Med Hyg 1984,33: Phillips-Howrd PA: Epidemiologicl nd control issues relted to mlri in pregnncy. Ann Trop Med Prsitol 1999, 93: S11-S17 3. Brbin BJ. An nlysis of mlri in pregnncy in Afric. Bull WHO 1983, 61: McGregor IA, Wilson ME, Billewicz WZ: Mlri infection of the plcent in The Gmbi, West Afric; its incidence nd reltionship to stillbirth, birthweight nd plcentl weight. Trns R Soc Trop Med Hyg 1983, 77: Redd SC, Wirim JJ nd Steketee RW: Risk fctors for nemi in young children in rurl Mlwi. Am J Trop Med Hyg 1994, 51: McCormick MC: The contribution of low birth weight to infnt mortlity nd childhood morbidity. N Engl J Med 1985,12: UNAIDS/WHO (2001): Globl HIV/AIDS Epidemic Updte: December, 2001 (UNAIDS), Genev. 8. Allen S, de Perre P, Serufilir A, et h Humn immunodeficiency virus nd mlri in representtive smple of childbering women in Kigli, Rwnd. Journ Infect Dis 1991, 64: Steketee RW, Wirim JJ, Blolnd PB, et l: Impirment of pregnnt women's cquired bility to limit Plsmodium flciprum by infection with humn immunodeficiency virus infection in Mlwi. Am J Trop Med Hyg 1996, 55: 42-9.

20 Verhoeff FH, Brbin BJ, Chimsuku L, Kzembe P, Russell WB, Brodhed RL: An evlution of the effects of intermittent sulfdoxine-pyrimethmine tretment in pregnncy on prsite clernce nd risk of low birthweight in rurl Mlwi. Ann Trop Med Prsitol. 1998,92: Prise ME, Ayisi JG, Nhlen BL, et t. Efficcy of sulfdoxine-pyrimethmine for prevention of plcentl mlri in n re of Keny with high prevlence of mlri nd humn immunodeficiency virus infection. Am J Trop Med Hyg 1998,59: Brbin L, Verhoeff FH, Kzembe P, Brbin BJ, Chimsuku L.Brodhed R: Improving ntentl cre for pregnnt dolescents in Southern Mlwi. Act Obstet Gynecol Scnd 1998, 77: Verhoeff FH, Brbin BJ, Hrt CA, Chimsuku L, Kzembe P, Brodhed RL: Incresed prevlence of mlri in HIV-infected pregnnt women nd its implictions for mlri control. Trop Med Intern Hlth 1999, 4: Weiss HA nd De Cock KM. The globl epidemiology of HIV/AIDS. Trop Med Intern Hlth 2000, 5: Whitworth J, Morgn D, Quigley M, et t Effect of HIV-1 nd incresing immunosuppression on mlri prsitemi nd clinicl episodes in dults in rurl Ugnd: cohort study. Lncet 2000, 356: French N, Nkiyingi J, Lugd E, Wter C, Whitworth JA, Gilks CF.: Incresing rtes of mlril fever with deteriorting immune sttus in HIV- 1-infected Ugndn dults. AIDS 2001,15: Villr J, Belizn JM. The reltive contribution of premturity nd fetl growth retrdtion to low birth weight in developing nd developed societies. Am J Obstet Gynecol 1982,143:

21 18. Brbin BJ. The risks nd severity of mlri in pregnnt women. 20 UNDP/World Bnk/WHO progrmme for Reserch nd Trining in Tropicl Diseses Reserch (TDR). Applied Field Reserch in Mlri Reports No. 1; McDermott JM, Slutsker L, Steketee RW, Wirim JJ, Bremn JG, Heymnn DL: Prospective ssessment of mortlity mong cohort of pregnnt women in rurl Mlwi. Am J Trop Med Hyg 1996, 55: Moore RD: Humn immunodeficiency virus infection, nemi, nd survivl. Clin Infect Dis 1999, 29: vn Eijk A, Ayisi J, ter Kuile FO et t Humn immunodeficiency virus seropositivity nd mlri s risk fctors for third-trimester nemi in symptomtic pregnnt women in western Kenyn. Am J Trop Med Hyg 2001;65: Blolnd PB, Lckritz EM, Kzembe PN, Were JB, Steketee R, Cmpbell CC: Beyond chloroquine: implictions of drug resistnce for evluting mlri therpy efficcy nd tretment policy in Afric. J Infect Dis 1993,167 : Ministry of Helth: Clinicl Guidelines for Dignosis nd Tretment of Common Hospitl Conditions in Keny. Government of Keny, Ministry of Helth, Nirobi, Keny Ayisi JG, vn Eijk A, ter Kuile FO et t Risk fctors for HIV infection mong symptomtic pregnnt women ttending n ntentl clinic in western Keny. Int J STD AIDS 2000,11: Bllrd JL, Novk KK, Driver M: A simplified score for ssessment of fetl mturtion of newly born infnts. JPeditr 1979, 95:

22 World Helth Orgniztion: Prevention nd mngement of severe nemi in pregnncy. Genev: World Helth Orgniztion, 1993 (WHO/FHE/MSM/93.5) 27. Verhoeff FH, Brbin BJ, Chimsuku L, Kzembe P, Brodhed RL: An nlysis of the determinnts of nemi in pregnnt women in rurl Mlwi bsis for ction. Ann Trop Med Prsitol 1999, 93: World Helth Orgniztion: Development of indictors for monitoring progress towrds helth for ll by the yer World Helth Orgniztion, Genev, (Helth for ll series. Volume 4); Willims RL, Cresy RK, Cunninghm GC, Hwes WE, Norris FD, Tshiro M: Fetl growth nd perintl vibility in Cliforni. Obstet Gynecol 1982, 59: Aitken M, Anderson D, Frncis B, Hinde J. Multinomil nd Poisson Response Dt. In: Sttisticl Modelling in Glim. Oxford Science Publictions, Oxford; 1989: Pges Agresti A. Ctegoricl Dt Anlysis. John Wiley & sons Inc., New York; 1990: Pges Powers DA. Logliner Models for Contingency Tbles. In: Sttisticl Methods for Ctegoricl Dt Anlysis. Acdemic Press, Sn Diego; 2000: Pges Christensen R. Log-Liner Models. Springer-Verlg, New York; 1990: 34. Kleinbum DG, Kupper LL & Muller KE: Confounding nd interction in regression. In: Applied regression nlysis nd other multivrible Methods, 2 nd edn. Edited by Pyne M. Belmont, Cliforni: Duxbury press; 1994: Brddick MR, Kreiss JD, Embree JE, et l: Impct of mternl HIV infection on obstetricl nd erly neontl outcome. AIDS 1990, 4:

23 Mmiro F, Ndugw C, Guy L, et l: Effect of humn immunodeficiency virus-1 infection on the outcome of pregnncy in Ugndn women. Peditr AIDS HIV infect Fetus Adolesc 1993,4: Ryder RW, Ns W, Hssig SE, et h Perintl trnsmission of humn immunodeficiency virus typel (HIV) to infnts of seropositive women in Zire. N Engl J Med 1989, 320: Leroy V, Ldner J, Nyirzirje M, et l: Effect of HIV-1 infection on pregnncy outcome in women in Kigli, Rwnd, Pregnncy nd HIV Study Group. AID? 1998,12: Vn Den Broek NR, White SA, Neilson JP: The reltionship between symptomtic humn immunodeficiency virus infection nd prevlence nd severity of nemi in pregnnt women. Am J Trop Hyg 1998, 59: Steketee RW, Wirim JJ, Hightower AW, Slutsker L, Heymnn DL, Bremn JG: The effect of mlri nd mlri prevention in pregnncy on offspring birthweight, premturity, nd intruterine growth retrdtion in rurl Mlwi. Am J Trop Med Hyg 1996, 55: Blolnd PB, Wirim JJ, Steketee RW, Chilim B, Hightower A, Bremn JG. Mternl HIV infection nd infnt mortlity in Mlwi: evidence for incresed mortlity due to plcentl mlri infection. AIDS 1995, 9: Were EO nd Krnj JK: Low birth weight t the Nynz Generl Hospitl Kisumu, Keny. EstAfrMedJ 1994, 71:

24 Figure 1. Flowchrt of inclusion nd exclusion of study women for nlysis Screened t ANC 75 No lb results, excluded 5093 Hd HIV results 2554 Delivered elsewhere, excluded 2539 Delivered t NPGH 36 Multiple deliveries, excluded 37 No PM results, excluded 2466 Singletons 34 Stillbirths, excluded 2432 Live singletons Abbrevitions: ANC: Antentl Cre Clinic HIV: humn immunodeficiency virus PM: Plcentl mlri NPGH: Nynz Provincil Generl Hospitl

25 Figure The effect of single nd dul infections with HIV nd mlri on men birth weight djusted potentil confounding covrites* by grvidity, Kisumu, western Keny, June 1996-Mrch, 1999 Primigrvide Multigrvide 2800 No infection MV-tne Mlri-tone Dul infection Mternl sttus 'Adjusted for mternl weight (< 25 percentile versus 25 percentile, kg), mternl ge (< 20 vs ;>20 yers), yers of eduction (< 8 vs z 8 yers), ethnicity (Luo vs non Luo), seson of delivery (riny vs dry), hospitliztion in pregnncy nd gender of the child nd Hb t delivery. Error brs indicte the 95% confidence intervl for men estimtes. Abbrevition: HIV: humn immunodeficiency virus

26 Figure The effect of single nd dul infections with HIV nd mlri on men hemoglobin djusted potentil confounding covrites bv grvidity. Kisumu. x 11 *f,f if T t Primigrvide Multigrvide 9- No infection HIV-tone Mlri-tne Dul infection Mternl sttus 'Adjusted for mternl weight (< 25 percentile versus ^25 percentile, kg), mternl ge (< 20 vs ^20 yers), yers of eduction (< 8 vs z 8 yers), ethnicity (Luo vs non Luo), seson of delivery (riny vs dry), hospitliztion in pregnncy, gender of the child, type of delivery (cesren section or ssisted delivery vs norml delivery) nd use of hemtinics. Error brs indicte the 95% confidence intervl for men estimtes. Abbrevition: HIV: humn immunodeficiency virus. Error brs indicte the 95% confidence intervl for men estimtes.

27 Tble 1. Chrcteristic?of women, with singleton delivery, with nd without n 26 dverse outcome t delivery, Provincil hospitl, Kisumu, Keny, June 1996-Mrch 1999 Adverse event* No dverse Risk Rtio Totl (N=670) event (N= 1796) (95% (N=2466) No with % No % confidence No % fctor with intervl) with fctor fctor Age < 20 yers Primigrvide lt 1.24( ) f 1.18( ) ^ 8 yers of f 0.94( ) eduction Unemployed Mrried Luo ethnicity Urbn residence Syphilis (RPR)+ { 3 rd trimester mlri Hb < 8 g/dl 3 rd trimester { HIV+ Mlri t delivery Dul infection lt 1.06( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) lt 1.56( ) ( )

28 27 Vginl delivery ( ) (unssisted) Breech or trnsverse presenttion, ssisted deliveries (forceps/vcuum extrction), cesren sections, nd intrprtum medicl complictions such s plcentl bruption, plcent previ nd pre-eclmpsi nd postprtum hemorrhge (ll combined) were uncommon, occurring less thn 5%. 'Adverse outcome: Either still birth, premture, low birth weight infnt, or smll-for- gesttionl-ge infnt, or mternl moderte to severe nemi t the time of delivery. For 269 women (10.9%) no hemoglobin ws vilble t the time of delivery, for 2, 64 (2.6%) nd 62 (2.5%) infnts there ws no informtion on low birth weight, smll for gesttionl ge or premturity respectively. t P< 0.05, compring women with nd without n dverse event t delivery X Hemoglobin 3 rd trimester missing for 28 women (1.1%), syphilis test result not vilble for 178 women (7.2%)

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