Increased prevalence of severe malaria in HIV-infected adults in South Africa

Background. Conflicting reports exist regarding the impact of human immunodeficiency virus (HIV) infection on the risk of severe malaria. We aimed to assess the effect of HIV infection status, advancing immunosuppression, and antimalarial immunity on the severity of malaria. Methods. A prospective cohort study was conducted. Consecutive hospitalized adult patients with falciparum malaria were tested for HIV antibodies and to determine CD4(+) T cell count. Immunity to malaria was assessed by obtaining a history of childhood residence in an area where malaria is endemic. Patients were assessed for features of severe malaria. Results. Three hundred thirty-six patients were enrolled in the study, of whom 32 ( 10%) had severe malaria. The prevalence of HIV infection was 33%, and 111 patients ( 33%) were nonimmune to malaria. HIV-infected patients complained more frequently about respiratory and abdominal symptoms and less frequently about rigors and headache. Risk factors for severe malaria determined by multivariate analysis included being nonimmune to malaria, having a positive HIV serostatus, having an elevated parasite count, and having an increased white blood cell count. Risk of severe malaria was increased in HIV-infected patients with a CD4(+) T cell count of < 200 x 10(6) cells/L (P <=.001). Nonimmune HIV-infected patients were significantly more likely to have severe malaria (13 [36%] of 36 patients) than were nonimmune non-HIV-infected patients (9[12%] of 75 patients; odds ratio, 4.15 [95% confidence interval, 1.57-10.97];). HIV serostatus did not affect risk of severe malaria in the group from an area with endemicity (5[7%] of 74 HIV-infected patients had severe malaria, and 5[3%] of 151 non HIV-infected patients had malaria; P=.248). Conclusions. HIV-infected nonimmune adults are at increased risk of severe malaria. This risk is associated with a low CD4(+) T cell count. This interaction is of great public health importance.