Helminthic Infections Rates and Malaria in HIV-Infected Pregnant Women on Anti-Retroviral Therapy in Rwanda Emil Ivan 1,2,3 , Nigel J. Crowther 3 , Eugene Mutimura 4 , Lawrence Obado Osuwat 5 , Saskia Janssen 6,7 , Martin P. Grobusch 6,7 * 1 Kigali Health Institute Department of Biomedical Laboratory Sciences, Kigali, Rwanda, 2 Rwanda Biomedical Centre National Reference Laboratory, Department of Laboratory Network, Kigali, Rwanda, 3 Department of Chemical Pathology, University of the Witwatersrand Medical School, National Health Laboratory Services, Parktown, Johannesburg, South Africa, 4 Women Equity in Access to Care and Treatment (WE-ACTx), Kigali, Rwanda and Regional Alliance for Sustainable Development (RASD Rwanda), Kigali, Rwanda, 5 Department of Medical Laboratory Science, School of Health Sciences, Mount Kenya University, Kigali, Rwanda, 6 Institute of Tropical Medicine, University of Tu ¨ bingen, Tu ¨ bingen, Germany, 7 Center of Tropical Medicine and Travel Medicine, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands Abstract Background: Within sub-Saharan Africa, helminth and malaria infections cause considerable morbidity in HIV-positive pregnant women and their offspring. Helminth infections are also associated with a higher risk of mother-to-child HIV transmission. The aim of this study was to determine the prevalence of, and the protective and risk factors for helminth and malaria infections in pregnant HIV-positive Rwandan women receiving anti-retroviral therapy (ART). Methodology and principle findings: Pregnant females (n = 980) were recruited from health centres in rural and peri-urban locations in the central and eastern provinces of Rwanda. Helminth infection was diagnosed using the Kato Katz method whilst the presence of Plasmodium falciparum was identified from blood smears. The prevalence of helminth infections was 34.3%; of malaria 13.3%, and of co-infections 6.6%. Helminth infections were more common in rural (43.1%) than peri-urban (18.0%; p,0.0005) sites. A CD4 count #350 cells/mm 3 was associated with a higher risk of helminth infections (odds ratio, 3.39; 95% CIs, 2.16–5.33; p,0.0005) and malaria (3.37 [2.11–5.38]; p,0.0005) whilst helminth infection was a risk factor for malaria infection and vice versa. Education and employment reduced the risk of all types of infection whilst hand washing protected against helminth infection (0.29 [0.19–0.46]; p,0.0005);). The TDF-3TC-NVP (3.47 [2.21–5.45]; p,0.0005), D4T-3TC- NVP (2.47 [1.27–4.80]; p,0.05) and AZT-NVP (2.60 [1.33–5.08]; p,0.05) regimens each yielded higher helminth infection rates than the AZT-3TC-NVP regimen. Anti-retroviral therapy had no effect on the risk of malaria. Conclusion/significance: HIV-positive pregnant women would benefit from the scaling up of de-worming programs alongside health education and hygiene interventions. The differential effect of certain ART combinations (as observed here most strongly with AZT-3TC-NVP) possibly protecting against helminth infection warrants further investigation. Citation: Ivan E, Crowther NJ, Mutimura E, Osuwat LO, Janssen S, et al. (2013) Helminthic Infections Rates and Malaria in HIV-Infected Pregnant Women on Anti- Retroviral Therapy in Rwanda. PLoS Negl Trop Dis 7(8): e2380. doi:10.1371/journal.pntd.0002380 Editor: Zvi Bentwich, Rosetta Genomics, Israel Received January 19, 2013; Accepted July 10, 2013; Published August 15, 2013 Copyright: ß 2013 Ivan et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: EI received a training award from WHO-TDR for three years. The Rwandan student funding agency SFAR funded the field work, with additional support from the Ministry of Health. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist. * E-mail: m.p.grobusch@amc.uva.nl Introduction Globally, the most common nematode species that cause soil- transmitted helminthic diseases are Ascaris lumbricoides, Trichuris trichiura, and the hookworm species Necator americanus and Ancylostoma duodenale [1,2,3]. Although morbidity due to helminths can be controlled by delivering preventive chemotherapy with antihelminthic medicines, elimination and finally eradication will not be achieved until affected populations have access to effective sanitation, sewage treatment and waste disposal; which remains a common problem in most rural African settings. In most of sub-Saharan Africa, the health burden of helminthic disease is enormous [4]. Co-infections with malaria and HIV are numerous and important causes of morbidity and mortality. Combating co-infections has been identified as an important public health goal [5]. Important areas of current research interests are the effects of helminth infections on immune regulation and their possible consequences for susceptibility to other infections and immunologically mediated conditions such as allergy and autoimmune diseases [6]. The immunological interplay between helminth infections and HIV is complex, and there are different hypotheses on the influence of the infections on each other; the most important being the Th2 bias induced by helminth infections, suppressing Th1 responses specific to HIV; thus leading to more rapid HIV progression [7,8]. HIV acquisition was positively correlated with female urogenital schistosomiasis [9] but in contrast, a randomized controlled trial (RCT) showed no benefit of deworming on prevention from mother to child transmission of HIV [10]. A few systematic reviews have been published describing the effect of anti-helminthic treatment on markers for HIV disease pro- gression showing inconsistently beneficial effects of anti-helminthic treatment; lower increases in HIV viral loads and increases in CD4 counts have been reported [11–13]. However, results from a PLOS Neglected Tropical Diseases | www.plosntds.org 1 August 2013 | Volume 7 | Issue 8 | e2380