Mike: Hello, I'm Mike Clarke, podcast editor for the Cochrane Library. Some Cochrane Reviews cut across more than one Cochrane Group. This is the case with the September 2024 update of the review of interventions for malaria and HIV in pregnancy. Here are two of the authors, Clara Pons-Duran and Raquel González from Barcelona University in Spain to tell us about the importance of the review and its findings.

Clara: Hi Raquel, how are you? First of all, could you please explain a little bit about malaria in pregnancy?

Raquel: Hi Clara, of course! Malaria is one of the most important parasitic diseases in the world, and pregnant women are one of the most vulnerable populations. An estimated 12.7 million women were exposed to malaria during pregnancy in sub-Saharan Africa in 2022. Malaria in pregnancy is associated with bad outcomes for the woman, her foetus, and the newborn child, such as increased risk of maternal death, spontaneous abortion, stillbirth, preterm birth, and low birth weight. And, in turn, these are major risk factors for perinatal and infant morbidity and mortality.

Clara: Moreover, malaria and HIV infection overlap geographically in sub-Saharan Africa and share determinants of risk, with HIV infection increasing malaria's severity especially in pregnant women. The World Health Organization recommends intermittent preventive treatment in pregnancy with sulphadoxine-pyrimethamine (SP) for all pregnant women living in malaria endemic areas. However, HIV-positive women taking daily cotrimoxazole to prevent opportunistic infections, cannot receive SP because of adverse drug interactions. This means that malaria prevention in this vulnerable population currently relies on daily cotrimoxazole prophylaxis alone.

Raquel: Exactly! Therefore, making safe and effective antimalarial drugs available to HIV-positive pregnant women remains an important global health need. Our review, which is an update of the 2011 Cochrane Review, evaluates alternative drugs for intermittent preventive treatment to prevent malaria in HIV-positive women who are pregnant. We wanted to compare the safety and efficacy of the regimens for malaria prevention in HIV-positive pregnant women and I’ll pass back to you to say what we found.

Clara: Sure! The review now includes 14 studies, with a total of very nearly 5000 HIV-positive women. The studies were conducted between 2002 and 2023 in 11 sub-Saharan African countries. All assessed the efficacy and safety of one antimalarial used as intermittent preventive treatment in pregnancy (mefloquine, dihydroartemisinin/piperaquine, SP, or azithromycin) with or without daily cotrimoxazole, compared to the cotrimoxazole alone, placebo, or a standard care regimen. The main results were:
- First: Adding an antimalarial drug such as mefloquine or dihydroartemisinin/piperaquine to daily cotrimoxazole, probably decreases the risk of placental malaria and maternal parastitemia at delivery. It may also reduce the risk of maternal serious adverse events, but with no effect on foetal loss or low birthweight.
- Then: Dihydroartemisinin/piperaquine added to daily cotrimoxazole reduced clinical malaria and placental infection. 
- Finally: Mefloquine added to daily cotrimoxazole probably reduces maternal parasitemia at delivery but may increase the risk of mother to child transmission of HIV.
To finish, Raquel, what would be the take home messages and how can people get hold of the full review?

Raquel: The key conclusions are that adding dihydroartemisinin/piperaquine and mefloquine to daily cotrimoxazole is likely to prevent malaria in HIV-positive pregnant women and may reduce the risk of adverse malaria-related outcomes. However, with mefloquine, there is increased risk of HIV transmission to the foetus and poor drug tolerability, which are barriers to recommending mefloquine for implementation in practice. In contrast, the evidence suggests that dihydroartemisinin/piperaquine is well tolerated and may be a suitable drug for intermittent preventive treatment in pregnancy for HIV-positive woman.
To get the review, listeners should go to Cochrane Library dot com and search ‘malaria and HIV in pregnancy’ to see a link to it near the top of the list.