Date Published: May 9, 2019
Publisher: Public Library of Science
Author(s): Uchechukwu M. Chukwuocha, Gregory N. Iwuoha, Geoffrey C. Nwakwuo, Peter K. Egbe, Chidinma D. Ezeihekaibe, Christopher P. Ekiyor, Ikechukwu N. S. Dozie, Sahai Burrowes, Andrew M. Blagborough.
This study assesses malaria prevention and treatment behaviour among people living with HIV/AIDS (PLWHA) in Owerri, South Eastern Nigeria. Although Nigeria bears one of the world’s largest burdens of both malaria and HIV, there is almost no research studying how co-infected patients manage their care. We systematically sampled 398 PLWHA receiving care at Imo State Specialist Hospital and the Federal Medical Centre in Owerri to complete a structured, pre-tested questionnaire on malaria care-seeking behaviour. Descriptive statistics were reported and chi-square tests and multivariate logistic regressions were also used. The majority of HIV-infected patients (78.9%) reported having had an episode of suspected malaria quarterly or more often. There was a large variation in care-seeking patterns: on suspicion of malaria, 29.1% of participants engaged in self-medication; 39.2% went to drug shops, and only 22.6% visited HIV/AIDS care centres. Almost 40% waited more than 24 hours before initiating treatment. Most (60.3%), reported taking recommended artemisinin-based combination treatments (ACT) but a significant minority took only paracetamol (25.6%) or herbal remedies (3.5%). Most (80%) finished their chosen course of treatment; and completion of treatment was significantly associated with the frequency of suspected malaria occurrence (p = 0.03). Most (62.8%) did not take anti-malaria medication while taking antiretroviral treatment (ART) and almost all (87.6%) reported taking an ACT regimen that could potentially interact with Nigeria’s first-line ART regimen. Our findings suggest the need to pay more attention to malaria prevention and control as a crucial element in HIV/AIDS management in this part of Nigeria and other areas where malaria and HIV/AIDS are co-endemic. Also, more research on ART-ACT interactions, better outreach to community-level drug shops and other private sector stakeholders, and clearer guidelines for clinicians and patients on preventing and managing co-infection may be needed. This will require improved collaboration between programmes for both diseases.
Malaria and HIV/AIDS overlap geographically in sub-Saharan Africa, Southeast Asia, and South America. Both diseases pose enormous global health challenges with each causing over three million deaths in 2007 and adversely affecting millions more each year [1, 2]. Nigeria has the world’s largest malaria burden with more than 50 million cases annually and approximately 200,000 malaria-related deaths each year . It also has the world’s second largest HIV/AIDS burden, with approximately 3.6 million people living with HIV/AIDS in 2016 . In Imo State, South Eastern Nigeria, an area reported to be holo-endemic for malaria , the HIV prevalence rate is now 7.5%, which is above the national average of 3.0% .
This study examined malaria care-seeking behaviour among HIV/AIDS patients receiving antiretroviral therapy in Southeastern Nigeria. We found extremely high levels of self-reported co-infection with all patients reporting having had suspected malaria and almost 80% reporting a suspected re-occurrence on at least a quarterly basis. Our data suggest that most of these suspected cases are never formally diagnosed but rather assumed to be malaria and treated as such. This highlights the need for greater access to rapid diagnostic tests, which were only used by 16.1% of our sample.
This study is limited by its narrow geographic scope and modest sample size and non-random sample selection strategy, which reduces its generalizability. The study is subject to both recall and social desirability bias as respondents may not remember past malaria episodes or treatment behaviour accurately and may report the health-seeking behaviour that they perceive as desirable. Problems with recall may be exacerbated by the fact that patients with a serious, life-threatening illness may be under great physical and emotional stress, which may impair memory. We attempted to address recall bias by having data collectors on-hand to reword or repeat questions, and prompt memory but this, in turn, may have introduced measurement error if questions were explained differently by different data collectors. The lack of back-translation of our survey instrument may have also introduced measurement error. Social desirability bias, if it occurred would have most likely lead to an under-reporting of the significant levels of informal care reported by participants. Finally, as noted at the start of this discussion, our estimates of malaria occurrence are based on self-report rather than diagnosis and, therefore, not precise. While this limits our ability to measure the level of co-infection in this population it does not greatly limit our ability to describe the care-seeking behaviour of these HIV-infected patients when they suspected that they have malaria.
This study has shown that PLWHA receiving ART in our sample self-report extremely high levels of suspected malaria, and that very little of their subsequent malaria care occurs in the formal sector. More worryingly, frequent bouts of suspected malaria seem to lead to interruptions in ART as most patients do not take ART and anti-malaria drugs simultaneously. Patients who do continue ART while treating malaria often use alternative, non-ACT anti-malaria drugs or herbal remedies, neither of which would tend to have well documented drug-drug interaction profiles with antiretroviral drugs. Our findings suggest the need for more research on ART-ACT interactions; better outreach to community-level drug shops and other private-sector stakeholders; and clearer guidelines for clinicians and patients on monitoring and managing co-infection. Wider access to rapid malaria diagnostic tests might also reduce the high level of presumptive malaria self-treatment that we find. Providing anti-malaria drugs for free in HIV care programs may also be worth exploring. Overall, we suggest that malaria prevention and control be viewed as an important element in the treatment HIV/AIDS patients in malaria-endemic countries such as Nigeria. This will require improved collaboration between programs for both diseases.