MAJOR ARTICLE Marked Reduction in Prevalence of Malaria Parasitemia and Anemia in HIV-Infected Pregnant Women Taking Cotrimoxazole With Or Without Sulfadoxine-Pyrimethamine Intermittent Preventive Therapy during Pregnancy in Malawi Atupele Kapito-Tembo, 1,2 Steven R. Meshnick, 1 Michae ¨ l Boele van Hensbroek, 6,7 Kamija Phiri, 3 Margaret Fitzgerald, 5 and Victor Mwapasa 3,4 1 Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina–Chapel Hill, Chapel Hill, North Carolina; 2 Ministry of Health and Population, Lilongwe; 3 Malawi–Liverpool–Wellcome Trust Clinical Research Programme, College of Medicine, Blantyre; 4 Department of Community Health, College of Medicine, Blantyre; 5 Me ´decins Sans Frontie `res (Belgium), Thyolo, and Malawi; 6 Emma Children's Hospital Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands; and 7 Liverpool School of Tropical Medicine, Liverpool, United Kingdom Background. Effectiveness of cotrimoxazole (CTX) compared with sulfadoxine-pyrimethamine (SP) intermittent-preventive-therapy (IPTp) for malaria in HIV-infected pregnant women is unknown. We examined effectiveness of CTX with or without SP-IPTp versus SP-IPTp at reducing malaria parasitemia and anemia. Methods. From 2005 to 2009, we conducted a cross-sectional study of HIV-infected pregnant women at Thyolo Hospital, Malawi. Blood was tested for malaria parasitemia and anemia (hemoglobin,11g/dl). Data were collected on use of anti-malaria interventions and other risk factors. CTX prophylaxis policy for HIV-infected pregnant women was introduced in 2007, but implementation problems resulted in some women receiving both CTX and SP-IPTp. Findings. We enrolled 1,142 women, of whom 1,121 had data on CTX and/or SP-IPTp intake. Of these, 49.7%, 29.8%, and 15.4% reported taking SP-IPTp only, CTX only and SP-IPTp plus CTX, respectively. Compared with women taking SP-IPTp, those taking SP-IPTp plus CTX and CTX were less likely to have malaria parasitemia (OR, [95%CI]: 0.09, [0.01-0.66] and 0.43, [0.19-0.97], respectively) or anemia (PR, [95% CI]: 0.67, [0.54-0.83] and 0.72, [0.61-0.83], respectively). Conclusion. In HIV-infected pregnant women, daily CTX was associated with reduced malaria parasitemia and anemia compared with SP-IPTp. CTX plus SP-IPTp was associated with further reduction in malaria parasitemia but toxicity was not fully assessed. Malaria in pregnancy is a preventable cause of signifi- cant maternal and perinatal morbidity and mortality in sub-Saharan Africa [1]. Human immunodeficiency vi- rus (HIV) infection increases the risks of placental and peripheral malaria, high-density parasitemia, and febrile malaria illness among pregnant women [2–5]. HIV- infected pregnant women are at an increased risk of premature delivery, severe anemia, delivery of low- birth-weight infants, and maternal death as a result of frequent and severe malaria infections [5]. In countries where malaria is endemic, women re- ceive sulfadoxine-pyrimethamine (SP) intermittent preventive therapy during pregnancy (IPTp) to prevent Received 6 April 2010; accepted 8 November 2010. Potential conflicts of interest: none reported. Reprints or correspondence: Dr Victor Mwapasa, Dept of Community Health, College of Medicine, Mahatma Gandhi Campus, Microbiology Bldg, Private Bag 360, Chichiri, Blantyre 3, Malawi (vmwapasa69@gmail.com). The Journal of Infectious Diseases 2011;1–9 Ó The Author 2011. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/ 2.5), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 1537-6613/2011/2034-0001$15.00 DOI: 10.1093/infdis/jiq072 Reduced Malaria with Cotrimoxazole in HIV1 Pregnant Women d JID 2011 d 1 Journal of Infectious Diseases Advance Access published January 7, 2011 by guest on January 9, 2011 jid.oxfordjournals.org Downloaded from