Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Increased severe anemia in HIV-1-exposed and HIV- 1-positive infants and children during acute malaria Richard O. Otieno a,b , Collins Ouma b,c , John M. Ong’echa b , Christopher C. Keller d , Tom Were b,e , Eliud N. Waindi a , Marian G. Michaels f , Richard D. Day g , John M. Vulule h and Douglas J. Perkins b,d Objective: Since the primary hematological complication in both pediatric HIV-1 and malaria is anemia, co-infection with these pathogens may promote life-threatening severe malarial anemia (SMA). The primary objective of the study was to determine if HIV-1 exposure [HIV-1(exp)] and/or HIV-1 infection [HIV-1(þ)] increased the preva- lence of SMA in children with acute malaria. Design: The effect of HIV-1 exposure and HIV-1 infection on the prevalence of SMA (hemoglobin < 6.0 g/dl), parasitemia (parasites/ml), and high-density parasitemia (HDP,  10 000 parasites/ml) was investigated in children  2 years of age presenting at hospital with acute Plasmodium falciparum malaria in a rural holoendemic malaria transmission area of western Kenya. Methods: Upon enrollment, a complete hematological and clinical evaluation was performed on all children. Malaria parasitemia was determined and children with acute P. falciparum malaria were evaluated for HIV-1 exposure and infection by two rapid serological antibody tests and HIV-1 DNA PCR, respectively. Results: Relative to HIV-1() group (n ¼ 194), the HIV-1(exp) (n ¼ 100) and HIV-1(þ) (n ¼ 23) groups had lower hemoglobin concentrations (P < 0.001 and P < 0.001, respectively), while parasitemia and HDP were equivalent between the three groups. Multivariate analyses demonstrated that the risk of SMA was elevated in HIV-1(exp) children (odds ratio, 2.17; 95% confidence interval, 1.25–3.78; P < 0.01) and HIV- 1(þ) children (odds ratio, 8.71; 95% confidence interval, 3.37 – 22.51; P < 0.0001). The multivariate model further revealed that HIV-1 exposure or infection were not signifi- cantly associated with HDP. Conclusions: Results presented here demonstrate that both HIV-1 exposure and HIV-1 infection are associated with increased prevalence of SMA during acute P. falciparum infection, independent of parasite density. ß 2006 Lippincott Williams & Wilkins AIDS 2006, 20:275–280 Keywords: HIV-1, hematological complications, severe malarial anemia, pediatric HIV From the a Department of Zoology, Maseno University, Kisumu, Kenya, the b University of Pittsburgh/KEMRI Laboratories of Parasitic and Viral Diseases, Centre for Vector Biology and Control Research, Kisumu, Kenya, the c Department of Pre-Clinical Sciences, School of Health Sciences, Kenyatta University, Nairobi, Kenya, the d Department of Infectious Diseases and Microbiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA, the e Department of Pathology, School of Health Sciences, Kenyatta University, Nairobi, Kenya, the f Department of Pediatrics, University of Pittsburgh Children Hospital, Pittsburgh, Pennsylvania, USA, the g Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA, and the h Kenya Medical Research Institute, Centre for Vector Biology and Control Research, Kisumu, Kenya. Correspondence to D.J. Perkins, Department of Infectious Diseases and Microbiology, Graduate School of Public Health, University of Pittsburgh, 603 Parran Hall, 130 Desoto St., Pittsburgh, PA 15261, USA. Tel: +1 412 624 5894; fax: +1 412 624 4953; e-mail: djp@pitt.edu Received: 30 August 2005; revised: 28 September 2005; accepted: 6 October 2005. ISSN 0269-9370 Q 2006 Lippincott Williams & Wilkins 275