What Works for Women and Girls

pregnancies as a consequence of repeated exposure (Fried et al., 1998 cited in Gamble et al.,2007).However, increasing evidence suggests that women who are living with HIV have the samelow immunity to malaria in subsequent pregnancies as they do in their first pregnancy andare twice as susceptible to clinical malaria, which can increase the risk of adverse outcomes(Van Eijk et al., 2003 cited in Brentlinger et al., 2006). For example, co-infection increaseswomen’s risk of developing severe anemia. It can also restrict fetal growth, reduce the transferof maternal immunities to other infectious diseases from mother to child, and cause pre-termdelivery and low birth weight.There is recent evidence that shows a link between HIV and malaria co-infection in pregnantwomen and low birth weight newborns. At the same time, low birth weight infantshave been shown to have significantly higher risks of mother-to-child transmission of HIVcompared with infants of normal birth weight. However, studies evaluating the impact of HIVand malaria co-infection on mother-to-child transmission have revealed mixed results, withsome showing greater risk, and others reporting no change (Ter Kuile et al, 2004; Kublin etal., 2005 cited in Brentlinger et al., 2006; Desai et al., 2007; WHO, 2005; UNICEF, 2003a;WHO, 2008c; UNICEF, 2009).Significant gaps remain in how to treat HIV-positive women who are sick with malaria,especially during pregnancy. “Studies of the synergy or antagonism between antiretroviralsand antimalarials are …essential to ensure effective and safe malaria case management…andHIV treatment for pregnant women” (Ward et al., 2008: 141). Further evidence on malaria andpregnancy is available at: www.mip-consortium.org.The Interactions Between HIV and Malaria Are Not Well Understood“Although the consequences of co-infection with HIV and malaria parasites are not fully understood,available evidence suggests that the infections act synergistically and together result inworse outcomes” (Skinner-Adams et al., 2008: 264). “Despite the wide prevalence of malariaand HIV in many parts of the tropics, knowledge of how these two important diseases interactis still hampered by lack of knowledge in many key areas…drug interactions form only a verysmall part of the potentially massive number of ways in which HIV and malaria interact to thedetriment of human health” (Khoo et al., 2005).Countries with Unstable Rates of Malaria Transmission Require Special AttentionIn areas where malaria occurs at regular intervals, those who survive repeated malarial infectionsacquire partial immunity by the age of five and carry it into their adult lives. Adultsin areas with regular malaria usually experience mild infections. However in areas wheremalaria occurs at irregular rates (regions with unstable malaria transmission), immunity isnot acquired and malaria can more easily result in death. Countries with high HIV prevalenceand unstable malaria transmission include: Botswana, Namibia, South Africa, Swaziland andZimbabwe (Idemyor, 2007). In a study of an area of South Africa with unstable malaria transmission,HIV-positive adults with malaria were significantly more likely to die (Grimwade et278 CHAPTER 10 PREVENTING, DETECTING AND TREATING CRITICAL CO-INFECTIONS