Antiretroviral agents and prevention of malaria in HIV-infected Ugandan children

N Engl J Med. 2012 Nov 29;367(22):2110-8. doi: 10.1056/NEJMoa1200501.

Abstract

Background: Human immunodeficiency virus (HIV) protease inhibitors show activity against Plasmodium falciparum in vitro. We hypothesized that the incidence of malaria in HIV-infected children would be lower among children receiving lopinavir-ritonavir-based antiretroviral therapy (ART) than among those receiving nonnucleoside reverse-transcriptase inhibitor (NNRTI)-based ART.

Methods: We conducted an open-label trial in which HIV-infected children 2 months to 5 years of age who were eligible for ART or were currently receiving NNRTI-based ART were randomly assigned to either lopinavir-ritonavir-based ART or NNRTI-based ART and were followed for 6 months to 2 years. Cases of uncomplicated malaria were treated with artemether-lumefantrine. The primary end point was the incidence of malaria.

Results: We enrolled 176 children, of whom 170 received the study regimen: 86 received NNRTI-based ART, and 84 lopinavir-ritonavir-based ART. The incidence of malaria was lower among children receiving the lopinavir-ritonavir-based regimen than among those receiving the NNRTI-based regimen (1.32 vs. 2.25 episodes per person-year; incidence-rate ratio, 0.59; 95% confidence interval [CI], 0.36 to 0.97; P=0.04), as was the risk of a recurrence of malaria after treatment with artemether-lumefantrine (28.1% vs. 54.2%; hazard ratio, 0.41; 95% CI, 0.22 to 0.76; P=0.004). The median lumefantrine level on day 7 after treatment for malaria was significantly higher in the lopinavir-ritonavir group than in the NNRTI group. In the lopinavir-ritonavir group, lumefantrine levels exceeding 300 ng per milliliter on day 7 were associated with a reduction of more than 85% in the 63-day risk of recurrent malaria. A greater number of serious adverse events occurred in the lopinavir-ritonavir group than in the NNRTI group (5.6% vs. 2.3%, P=0.16). Pruritus occurred significantly more frequently in the lopinavir-ritonavir group, and elevated alanine aminotransferase levels significantly more frequently in the NNRTI group.

Conclusions: Lopinavir-ritonavir-based ART as compared with NNRTI-based ART reduced the incidence of malaria by 41%, with the lower incidence attributable largely to a significant reduction in the recurrence of malaria after treatment with artemether-lumefantrine. Lopinavir-ritonavir-based ART was accompanied by an increase in serious adverse events. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development; ClinicalTrials.gov number, NCT00978068.).

Publication types

  • Comparative Study
  • Randomized Controlled Trial
  • Research Support, N.I.H., Extramural

MeSH terms

  • Anti-Retroviral Agents / therapeutic use*
  • Antimalarials / pharmacokinetics
  • Antimalarials / therapeutic use
  • Artemether, Lumefantrine Drug Combination
  • Artemisinins / pharmacokinetics
  • Artemisinins / therapeutic use
  • Child, Preschool
  • Drug Combinations
  • Drug Interactions
  • Drug Therapy, Combination
  • Ethanolamines / pharmacokinetics
  • Ethanolamines / therapeutic use
  • Female
  • Fluorenes / pharmacokinetics
  • Fluorenes / therapeutic use
  • HIV Infections / drug therapy*
  • HIV Protease Inhibitors / therapeutic use
  • Humans
  • Incidence
  • Infant
  • Kaplan-Meier Estimate
  • Lopinavir / therapeutic use*
  • Malaria / drug therapy
  • Malaria / epidemiology
  • Malaria / prevention & control*
  • Male
  • Reverse Transcriptase Inhibitors / therapeutic use
  • Ritonavir / therapeutic use*
  • Secondary Prevention
  • Uganda

Substances

  • Anti-Retroviral Agents
  • Antimalarials
  • Artemether, Lumefantrine Drug Combination
  • Artemisinins
  • Drug Combinations
  • Ethanolamines
  • Fluorenes
  • HIV Protease Inhibitors
  • Reverse Transcriptase Inhibitors
  • Lopinavir
  • Ritonavir

Associated data

  • ClinicalTrials.gov/NCT00978068