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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 6  |  Issue : 2  |  Page : 46-51

Malaria and human immunodeficiency virus coinfection in febrile patients attending the Regional Hospital of Buea, Southwest region, Cameroon


1 Department of Biomedical Science, Faculty of Health Sciences, University of Buea, Yaoundé, Cameroon
2 Regional Hospital Buea; Department of Microbiology and Parasitology, Faculty of Science, University of Buea, Yaoundé, Cameroon
3 Regional Hospital Buea; Department of Microbiology and Parasitology, Faculty of Science, University of Buea; Department of Public Health and Hygiene, Faculty of Health Sciences, University of Buea, Yaoundé, Cameroon
4 Department of Biomedical Science, Faculty of Health Sciences; Regional Hospital Buea, Faculty of Science, University of Buea, Yaoundé, Cameroon
5 Local Government Training Centre, CEFAM Buea, Southwest Region, Yaoundé, Cameroon
6 Department of Medical Laboratory Sciences, Faculty of Health Sciences, University of Buea, Yaoundé, Cameroon
7 METABIOTA Cameroon, BP, Yaoundé, Cameroon
8 Department of Biomedical Science, Faculty of Health Sciences; Regional Hospital Buea; Department of Public Health and Hygiene; Department of Medical Laboratory Sciences, Faculty of Health Sciences, University of Buea, Yaoundé, Cameroon

Date of Submission14-Feb-2019
Date of Acceptance14-Sep-2019
Date of Web Publication02-Jan-2020

Correspondence Address:
Dr. Tebit Emmanuel Kwenti
Faculty of Health Sciences, University of Buea, Buea, Southwest Region
Cameroon
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJAMR.IJAMR_24_19

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  Abstract 


Background: Malaria and human immunodeficiency virus (HIV) account for significant morbidity and mortality in Cameroon. Studies on malaria and HIV coinfection in the Southwest Region of the country are few. The aim of this study was to determine the prevalence of malaria and HIV coinfection as well as the association between HIV and severe malaria (SM), in febrile patients attending the Regional Hospital of Buea. Materials and Methods: In this cross-sectional study, 218 febrile patients were enrolled from the Outpatient Department/Emergency Unit of the Regional Hospital of Buea. Their vital signs were collected, and the consulting physician examined them. Their HIV and malaria statuses were determined by serology and Giemsa microscopy, respectively. SM was classified according to the WHO criteria. Results: The participants' age ranged between 2 weeks and 79 years, and the majority were females (59.2%). The prevalence of malaria, HIV, and coinfection with malaria and HIV were 30.7%, 6.9%, and 2.3%, respectively. Malaria prevalence was significantly higher in children 10 years and below (P = 0.018); meanwhile, HIV prevalence was significantly higher in participants between 31 and 40 years (P = 0.005). The mean hemoglobin concentration was significantly lower while the malaria parasite density was significantly higher in malaria and HIV-coinfected group. The rate of SM was 13.8%, and this was higher in children ≤10 years (P = 0.037). The association between HIV and SM was not statistically significant (P = 0.308). Conclusion: In general, a low prevalence of coinfection with malaria and HIV was observed, and HIV infection was not found to be associated with SM in this study. Further studies in other populations from Cameroon are required to shed more light.

Keywords: Buea, human immunodeficiency virus, malaria, severe malaria


How to cite this article:
Mbah-Mbole FG, Tufon KA, Meriki DH, Enow-Orock G, Mbah-Mbole P, Njunda LA, Wam Iwoi MD, Kwenti TE. Malaria and human immunodeficiency virus coinfection in febrile patients attending the Regional Hospital of Buea, Southwest region, Cameroon. Int J Adv Med Health Res 2019;6:46-51

How to cite this URL:
Mbah-Mbole FG, Tufon KA, Meriki DH, Enow-Orock G, Mbah-Mbole P, Njunda LA, Wam Iwoi MD, Kwenti TE. Malaria and human immunodeficiency virus coinfection in febrile patients attending the Regional Hospital of Buea, Southwest region, Cameroon. Int J Adv Med Health Res [serial online] 2019 [cited 2020 Jan 19];6:46-51. Available from: http://www.ijamhrjournal.org/text.asp?2019/6/2/46/274625




  Introduction Top


Malaria and human immunodeficiency virus (HIV) infection, two of the most deadly diseases of our time,[1],[2] are highly prevalent in sub-Saharan Africa. Due to their overlapping distribution, coinfection with malaria and HIV is common in the region. Studies that have been conducted in sub-Saharan Africa so far show the prevalence of malaria and HIV coinfection ranging from 0.7% to 47.5%.[2] Pregnant women and children are the groups most at risk of malaria and HIV coinfection.[2] Malaria and HIV in coinfected patients have been shown to interact biologically, clinically, and immunologically, thereby worsening the prognosis of either disease.[2] In coinfected patients, malaria leads to an increase in the HIV viral load and a decrease in the CD4 + T-cell count and increases the progression of HIV to AIDS.[2] On the other hand, HIV is associated with an increase of malaria parasite density and leads to a more frequent and more severe malaria (SM).[2]

In areas where malaria and HIV coexist, they both have an impact on the transmission of the other. In settings where malaria transmission is stable, HIV has been observed to increase the risk of malaria and clinical malaria in adults, especially in those with advanced immunosuppression.[3] Meanwhile, in settings where malaria transmission is unstable, HIV-infected adults have an increased risk of SM and malaria-associated mortality,[4] because adequate immunity against malaria is not readily acquired, thereby resulting in a higher proportion of malaria cases. On the other hand, malaria has been observed to be significantly associated with HIV infection in the Eastern[4] but not in the Western part of sub-Saharan Africa.[5]

Cameroon, like most countries in the sub-Saharan African region, is greatly affected by malaria and HIV. The national prevalence of malaria is estimated at 29%,[6] and children are the most affected.[7],[8],[9],[10],[11]Plasmodium falciparum is the predominant parasite species causing malaria in Cameroon.[12] The national prevalence of HIV currently stands at 3.7%, and young women are the most affected group.[13] Although there has been a decline in the prevalence of HIV in Cameroon recently, the number of people living with HIV (PLHIV) has been on the rise, increasing from 416,000 in 2000 to 560,000 in 2010, and with a projected increase of up to 726,000 by 2020.[14],[15] This, therefore, implies that there is an increasing number of PLHIV who are exposed to a number of infections including malaria. Coinfection with malaria and HIV is also common in the country; epidemiological studies conducted so far revealed the prevalence of coinfection ranging between 1.2% and 29.4%.[16],[17],[18],[19],[20] However, no research has been conducted to determine the prevalence of malaria and HIV coinfection in the Southwest Region of Cameroon. Moreover, no research has been conducted in the country to determine whether malaria and HIV in coinfected persons are associated with increased severity of the other. This study was, therefore, designed to determine the prevalence of malaria and HIV coinfection as well as the association between HIV and SM, in febrile patients enrolled at the Regional Hospital of Buea.


  Materials and Methods Top


Study area

This study was conducted in the Regional Hospital of Buea, in Buea. The town is located in Fako division of the Southwest Region of Cameroon. The study area is described in detail elsewhere.[21]

Study design

This was a cross-sectional study involving febrile patients enrolled from the Outpatient Department (OPD) of the Regional Hospital of Buea. The study was conducted between March and June 2018.

Study population

This study involved febrile patients, of both sexes, presenting with symptoms of malaria regardless of age. Participants who were not on any antimalarial drugs and who did not know their HIV status were enrolled. The blood pressure and temperature of the participants were collected, and they were examined by the consulting physician. Patients with positive results for malaria based on light microscopy were further categorized into the different types of SM as per the WHO criteria.[10],[11],[22]

Ethical consideration

The current study protocol was approved by the Institutional Review Board of the Faculty of Health Science, University of Buea. Written informed consent was obtained from all the participants.

Sampling technique

A time-limited sampling technique was used, where febrile patients were consecutively enrolled from the OPD of the Regional Hospital of Buea.

Sample size

The sample size was estimated using the following formula for sample size:



Z = 1.96

P = prevalence of coinfection with malaria and HIV in Cameroon = 17.3%.[18]

e = percentage of error to be allowed = 0.05



Thus, we enrolled 218 participants.

Sample collection

From every participant, about 3 ml of venous blood was collected into ethylenediaminetetraacetic acid-anticoagulated tubes following antiseptic techniques. The blood was used in the preparation of blood films (thick and thin) as well as screening for HIV.

Laboratory analysis

Measurement of blood glucose level

Blood glucose level was measured with a glucometer (On Call® Plus Blood Glucose Meter, ACON Laboratories, Inc., USA) by a finger prick.

Determination of the hemoglobin concentration and white blood cell count

Complete blood count (CBC) analysis was performed using the Mindray® Auto Hematology Analyzer (BC-2800, Shenzhen Mindray Bio-Medical Electronics Co., Ltd, Shenzhen, China). The hemoglobin (Hb) concentration and white blood cell (WBC) counts were deduced from the CBC results.

Detection of malaria parasites

Thick and thin blood films were prepared on grease-free glass slides, air-dried and stained with 20% Giemsa (1 in 20 dilutions) for 25–30 min.[23] The films were read by two expert microscopists who were blinded from the results of the other. Where there was any discrepancy in the results obtained by the two microscopists, a third was brought in, and the results he gave were considered as final. Two hundred fields were screened for malaria parasite using the oil immersion objective, and where parasites were detected, the parasites were counted until 500 WBC is reached. The slides were declared negative only after counting to 2500 WBC. Malaria parasite density was estimated by dividing the parasites counted (in the thick film) by 500 WBC and then multiplied by the actual WBC count obtained from the CBC results of the participant to give numbers in parasite per microliter.[24]

Screening for human immunodeficiency virus

HIV screening was performed in accordance with Cameroon's national algorithm for HIV screening by detecting anti-HIV antibodies.[25] Briefly, a first rapid test was used, and if positive, a second rapid test was used to confirm the result. In this study, the first rapid and second rapid tests were Determine™ HIV (Abbott Laboratories, Abbott Park, IL, USA) andFirst Response HIV-1-2 kits (Premier Medical Corporation Ltd., Kachigam, India) respectively. According to the manufacturer, the Determine™ HIV kit has a sensitivity and a specificity of 100% and 100%, respectively. Meanwhile, theFirst Response HIV-1-2 kit has a sensitivity and specificity of 100% and 82.86%, respectively.[26]

Categorization of malaria into uncomplicated and severe forms

Malaria was categorized into uncomplicated and SM according to the WHO scheme as described elsewhere.[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22]

Statistical analysis

The data collected were entered into an Excel spreadsheet and analyzed using SPSS version 16 (IBM, New York, USA) for Microsoft Windows. The statistical tests performed included the Pearson's Chi-square test for comparison of proportions and student's t-test and ANOVA for comparison of means. Statistical significance was set at P < 0.05.


  Results Top


Characteristics of the study population

Two hundred and eighteen febrile patients took part in this study. Among them, 129 (59.2%) were female and 89 (40.8%) were male. The age of the participants ranged between 0 and 79 years (mean ± standard deviation [SD] = 19.06 ± 16.96) [Table 1].
Table 1: Age distribution of the study population

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The mean (±SD) body temperature, Hb concentration, and blood glucose were 38.3°C (±0.71), 10.4 g/dl (3.2), and 78 mg/dl (±10.6), respectively.

Distribution of malaria and human immunodeficiency virus in the study population

Among the 218 participants, 72 were positive for malaria parasites, giving an overall prevalence of 33.03% (95% confidence interval [CI]: 26.8–39.7). P. falciparum was the only species identified in all positive malaria cases by light microscopy. Among the participants, 20 were diagnosed positive for HIV giving a prevalence of 10.1% (95% CI: 6.3–15.2).

Prevalence of malaria was highest in participants ≤10 years of age. The mean (±SD) age of the participants with and without malaria were 15.6 (±18.1) and 20.8 (±16.1), respectively. A significant association was observed between the prevalence of malaria and age group (χ2 =13.654, P = 0.018) [Figure 1].
Figure 1: Distribution of malaria and human immunodeficiency virus in the study population stratified according to age

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HIV prevalence was highest among participants between the age of 31–40 years (27.2%) [Figure 1]. The mean (±SD) ages of the participants with and without HIV were 29.7 (±14.1) and 18.0 (±16.9), respectively. The prevalence of HIV was also significantly associated with age group (χ2 =20.389, P = 0.005).

Malaria prevalence was 33.7% (30/89) and 32.6% (42/129) in males and females, respectively. The association between malaria prevalence and gender was not significant (χ2 =0.016, P = 0.899). Similarly, the prevalence of HIV was higher in males (12.4%, 11/89) compared to females (7.0%, 9/129). Like malaria, no significant association was observed between HIV prevalence and gender (χ2 =1.831, P = 0.176).

Distribution of severe malaria in the study population

The prevalence of SM in this study was 13.8% (30/218). The prevalence of SM was highest in children below 10 years (70%) [Table 2]. The mean (±SD) age of the participants with uncomplicated and SM were 19.2 (±14.3) and 13.3 (±15.2), respectively. A significant association was observed between the prevalence of SM and age group (χ2 = 11.872, P = 0.037). Furthermore, the rate of SM attack was higher in males (15.7%, 14/89) compared to females (12.4%, 16/129). However, no significant association was observed between the prevalence of SM and gender (χ2 = 0.491, P = 0.483).
Table 2: Distribution of severe malaria with age in the study population

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Clinical features of severe malaria

The most frequent manifestation of SM was severe malarial anemia (60.0%), followed by cerebral malaria (30.0%), and hyperparasitemia (23.3%) [Table 3].
Table 3: Distribution of clinical manifestations of severe malaria

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Coinfection with the malaria parasite and human immunodeficiency virus

Among the 72 patients who were positive for malaria in this study, 5 (6.9%) were found to be positive for both HIV and malaria [Figure 2]. Overall, the prevalence of malaria and HIV coinfection was 2.3% (95% CI: 0.8–5.3). There was no significant association between malaria and HIV (χ2 =1.831, P = 0.423).
Figure 2: Venn diagram displaying the prevalence of coinfection with malaria and human immunodeficiency virus

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The mean (±SD) Hb concentration was 12.5 (±3.1), 10.2 (±3.4), 9.4 (±2.6), and 6.8 (±2.1) for malaria/HIV negative, HIV monoinfected, malaria monoinfected, and malaria and HIV coinfection, respectively. The difference in the Hb concentration between the groups was significant (P = 0.003).

The overall geometric mean parasite density (GMPD) was 18,456.6 parasites/μl. The GMPD (±SD) was 16,765.8 (±807.4) parasites/μl in malaria-monoinfected patients and 23,453.7 (±1634.5) parasites/μl in malaria and HIV coinfection. The difference in the GMPD between malaria monoinfected and malaria and HIV coinfection was significant (P < 0.0001). Correlation analysis revealed no significant association between malaria parasite density and age (r = −0.187, P = 0.117).

Association between human immunodeficiency virus and severe malaria

Among the 30 cases of SM, only 1 (3.3%) was coinfected with HIV [Table 4]. No significant association was observed between HIV and SM (P = 0.308).
Table 4: Association of human immunodeficiency virus with severe malaria in the study population

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  Discussion Top


The current study revealed a high prevalence of malaria (33.03%), which is similar to the prevalence reported in other studies conducted in the area[8],[27],[28] and elsewhere in the country.[29] The high malaria prevalence observed in the current study could be attributed to the presence of environmental factors including the presence of bushes and stagnant water around residential areas, which favors the breeding of mosquitoes.[27],[30] The prevalence of malaria in the current study is also similar to the national prevalence of 29%.[6] Malaria prevalence in this study was highest in children (≤10 years), which is in line with other studies conducted in the area.[28],[30] In this study, P. falciparum was the only parasite species identified by microscopy as causing malaria in the study population. P. falciparum has previously been reported as the main cause of clinical malaria in Cameroon.[12] However, other species including Plasmodium vivax,[31]Plasmodium malariae, and Plasmodium ovale[10],[21] have also been reported in the area. However, their occurrence is generally very low.

Very few studies reporting the prevalence of SM and its phenotypes have been conducted in Buea and Cameroon in general. This study revealed a SM attack rate of 13.8%, which is similar to the 10.9% earlier reported in the study area by Kwenti et al.,[10] but lower compared to the 29.3% reported elsewhere in Cameroon,[11] and in other countries, including the 61.8% observed in a Ghanaian study.[32] The discrepancy between the prevalence of SM reported in the current study and the others could be attributed to differences in the study design; this study targeted adults in addition to children; meanwhile, the other studies targeted only children. SM has been observed to be more frequent in younger children (<5 years) compared to older children (>5 years) or adults.[11],[33] This is also confirmed by the finding of a relatively higher rate of SM in children (≤10 years) in this study. The higher rate of SM in children could be attributed to their weak immunity against the malaria parasites.[11] The susceptibility to malaria and SM attack generally decreases with increasing age as the number of exposure to the malaria parasites increases. Immunity to malaria in Cameroon has equally been shown to increase with age.[34],[35] In the current study, SM anemia, cerebral malaria, and hyperparasitemia were the most common features of SM in the current study which is also in conformity with earlier studies.[10],[11],[33],[36]

This study revealed a prevalence of 10.1% for HIV in the target population, which is in conformity with an earlier study conducted in the area.[37] However, it is higher compared to the national prevalence of 3.7%.[13] One factor that may be responsible for the higher prevalence of HIV in this study could be the fact that this study was conducted on febrile patients as opposed to the general population of Buea. The prevalence of HIV was significantly higher in participants between 31 and 40 years. HIV is generally known to be more common in adolescence and young adults, and this could be attributed to the heightened sexual activity of individuals in this age range. No difference was observed in the prevalence of HIV between males and females in this study.

The prevalence of malaria and HIV coinfection observed in this study was quite low (2.3%), which corroborates other studies conducted in Cameroon.[16],[20] However, the prevalence of malaria and HIV coinfection was lower compared to the 7.3% reported in Yaoundé,[19] and 29.4% reported in Douala.[17] This discrepancy could be attributed to differences in geographical settings. The low prevalence of malaria and HIV coinfection in this study could also be attributed to the differences in the age distribution of populations affected by both diseases. As earlier mentioned, malaria is more common in children and HIV in adults.

In the current study, malaria and HIV coinfection was observed to be significantly associated with low Hb concentration and higher malaria parasite density. This finding is suggestive that HIV worsens the prognosis of malaria in patients coinfected with malaria and HIV in the area. The findings of lower Hb and higher malaria parasite density in malaria and HIV coinfection are in line with the study by Nkuo-Akenji et al.[17] and Njunda et al.[19] However, this study revealed that there was no significant association between HIV and malaria or between HIV and SM. This study is the first to assess the association between HIV and SM in Cameroon, and the findings are in line with the study by Cuadros et al.,[5] which shows that HIV is not associated with malaria in western sub-Saharan Africa. The low prevalence of HIV, as well as the low prevalence of malaria and HIV coinfection observed in this study, may have accounted for the absence of any significant association between HIV and SM. Furthermore, if there was a true association between HIV and SM, a hospital-based study might miss out the true association because of Berksonian and/or survivor bias. Larger studies involving other populations in Cameroon will be required to shed more light.


  Conclusion Top


In this study, the prevalence of 33.03%, 10.1%, and 2.3% was observed for malaria, HIV, and coinfection with malaria and HIV, respectively. The malaria prevalence was significantly higher in children ≤10 years; meanwhile, HIV was significantly higher in the age group of 31–40 years. P. falciparum was the only parasite species identified as causing malaria in the target population. The prevalence of SM in this study was 13.8%, and it was higher in children ≤10 years. Significantly lower mean Hb concentration and higher parasite densities were observed in patients coinfected with malaria and HIV. There was no significant association between HIV and SM in the target population. Further studies will be required in other populations in Cameroon to shed more light.

Acknowledgment

We would like to thank the medical doctors, nurses, and laboratory technicians of the Regional Hospital of Buea for their contribution toward the realization of this work.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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