Evaluating the prevalence of HIV/Malaria co-infections in Uyo Akwa-Ibom State (Nigeria)

Bachelor Thesis 2019 58 Pages

Chemistry - Bio-chemistry


Table of Contents

1.1 Background of the study
1.2 Statement of the Problem
1.3. Aim of the study
1.4. Objectives of the study

2.1 Historical Background of HIV/AIDS
2.2 Types Of HIV Virus
2.3 Structure of HIV Virus
2.4 Genome of HIV Virus
2.5 Immunology Of HIV Virus
2.6. HIV Pathogenesis of HIV Virus
2.7 Opportunistic Infections
2.8 Epidemiology Of HIV Virus
2.9 Laboratory Diagnosis Of HIV
2.10 Treatment Of HIV
2.11 Prevention and Control Of HIV
2.12 Background of Malaria
2.13 History of Malaria
2.14 Natural History Of Malaria
2.15 Uncomplicated Malaria
2.16 Severe Malaria
2.17 Diagnosis Of Malaria
2.18 Epidemiology Of Malaria
2.19 HIV And Malaria Coinfection

3.1. Study Areas
3.2. Study Design
3.3. Sample Size
3.4. Ethical Approval
3.5 Study Population
3.6. Sample Collection
3.7. Serological Analysis
3.8. Data Analysis

4.1. Patients Characteristics
4.2. Overall prevalence of HIV/Malaria co-infections
4.3. Age-specific HIV/Malaria co-infections
4.4. Sex-specific HIV/Malaria co-infections
4.5. Marital Status-specific HIV/Malaria co-infections
4.6. Educational Status-specific HIV/Malaria co-infections
4.7. Occupation-specific HIV/Malaria co-infections







1.1 Background of the study

Human immunodeficiency virus (HIV) and malaria are two main worldwide health threats that affect development in low and middle-income countries (Granich et al., 2009). These infections have resulted in about 5 million deaths yearly with significant humanitarian, economic, and social impact, which is yet to be measured (Granich et al., 2009). These infections not only occur in the same geographic zone but are also said to be associated with poverty, and this has a major public health implication (WHO, 2008). It is a well-known opportunistic infection and also an important factor affecting the increased disease progression to AIDS in HIV-infected persons due to a significant increased destruction of active CD4 helper T-cells and a quick breakdown of immune functions.

A protist belonging to the genus Plasmodium is the causative agent for malaria, and this protist is transmitted by mosquitoes. The protist infects the liver first, then it acts as a parasite in the red blood cells, resulting in symptoms that usually includes high body temperature, severe head pains and coma or death in very serious cases.A serious form of malaria is mostly caused by P. falciparum while a milder disease which is not so serious is caused by P. vivax, P. ovale, and P. malariae (World Malaria report, 2011).Over 50% of the people on earth are vulnerable to the malaria infection and they are estimated over 300million malaria cases annually in the tropics. In 2016, Nigeria was responsible for malaria cases over 27% and mortality of about 24% all over the world. Some researches in Nigeria have shown that there is a high frequency of malaria among people infected with HIV (Onyenekwe et al., 2007). In a population-based study, HIV infected persons were more at risk of having Malaria than those that were not infected with the virus (Audu et al., 2005).

The high frequency of both HIV and malaria in the sub-Saharan region means that co-infection is relatively common, and the synergistic nature of the HIV-malaria partnership makes co-infection a major health concern. HIV infection impacts on malaria by suppressing the response of the immune system to Plasmodium invasion and several researchers maintain that malaria increases both in vivo and in vitro replication of the HIV (Onyenekwe et al., 2007).

Most deadly diseases in the world occur in the Sub-Saharan Africa. HIV/AIDS and Malaria are diseases that mostly affect the poor and contribute greatly to the high poverty level in sub-saharan Africa nations. These two diseases affect the younger population whose strength contribute to the growth of the local economy (Hochman et al., 2009). The risk and seriousness of Malaria disease is increased by HIV. Infection of HIV and malaria are amongst the two most crucial global health problems of developing countries and this includes Nigeria which was said to cause more than 4 million deaths annually (Alemu et al., 2013).

Furthermore, the rate at which malaria is transmitted is increased when there is HIV infection, and this brings about the activation of CD4 cells and an increased production of cytokines which makes the microenvironment suitable for the distribution of HIV among the CD4 cells to increase HIV-1 replication (Alimonti et al., 2003). Previous studies tried with difficulties to create an relationship between HIV and malaria (Marum et al., 1997), but recent researches have suggested that frequent malaria infection brings about a more faster decline in CD4+ T cells overtime meanwhile, malaria co-infection with HIV brings about regular occurrence of symptomatic malaria (Kamya et al., 2006) and more occurrence of serious or complicated malaria including death in both children and adults (Cohen et al., 2005).

Malaria was included in the list of AIDS-related opportunistic infections by the Centre for Disease Prevention and Control since 2009. Although malaria is not considered the major cause of death, it is the third most significant cause of ill-health in HIV/ AIDS infected individuals (Saracini et al., 2012). The synergistic nature of the HIV/malaria partnership makes co-infection a major health concern. Malaria is said to increase HIV replication in vitro and in vivo (Kamya et al., 2006). Additionally, evidence shows that malaria co-infection with HIV triggers malaria disease progression, increases the risk of severe malaria in adults (Whitworth et al., 2000), increases risk of congenital infection (Perrault et al., 2009) and this dual infection increases the distribution of both diseases particularly in sub-Saharan Africa (Patnaik et al., 2006). HIV-1 replication is increased by P. falciparum through the production of cytokines (interleukin-6 and tumor necrosis factor-alpha) by activated lymphocytes (Rudolph et al., 1998; Whitworth et al., 2004). There is an increase in the potential reservoir for HIV in the placenta the number of CCR5+ macrophages are increased by P. falciparum. (Moormann et al., 2001).

Although, previous study carried out by Okonko et al. (2019), on the frequency of HIV and Malaria sero-positivity amongst undergraduates at a tertiary healthcare Centre in Port Harcourt, Nigeria indicated no incidence of co-infection in this study. Consequently, the present study aimed at determining the prevalence of HIV/Malaria co-infections in HIV-1 infected individuals in Uyo, Nigeria.

1.2 Statement of the Problem

Nigeria is the most populous country in Africa with 2.9% HIV frequency, and it belongs to the West-Central African key region where the broadest diversity of HIV exists. Unfortunately, the sub-Saharan Africa that houses the majority of people living with HIV/AIDS (PLWHA) and in need of treatment and therapeutic monitoring is also home to a greatest genetic diversity of HIV-1 subtypes (Peeters et al., 2010)

1.3. Aim of the study

The aim of the study was to evaluate the prevalence of HIV/Malaria co-infections in HIV-1 infected individuals in Uyo Akwa-Ibom State,Nigeria.

1.4. Objectives of the study

The objectives of this study were to:

1. Determine the frequency of HIV/Malaria co-infection in blood of HIV infected individuals.
2. Examine the relationship between HIV/Malaria co-infections.
3. Describe the socio-demographic features and determine the risk correlates associated with HIV/Malaria transmission.


2.1 Historical Background of HIV/AIDS

In the past twenty-five years, AIDS has been a very serious threat to the health of people all over the world. This disease has critically affected the health of people and has hindered social and economic development. A lot of discrimination is attached to this disease, hence the reason it is difficult to control (WHO, 2008).This disease has taken the lives of over 25million people globally since the first cases were reported in 1981. There are many theories as to how the HIV virus (the virus that causes AIDS) developed in humans and the theory that is most widely accepted is that which says that humans contacted the virus by hunting some species of chimpanzees that carried the virus, and then eating them or getting their blood in an open wound (WHO, 2008). In 1981, the Centers responsible for disease control reported the cases of five young previously healthy homosexual men who were now infected with a rare yeast-like fungus called Pneumocystis carinii pneumonia (CDC, 1981).

The early cases of AIDS were reported in 1981 and more than 25 million people worldwide have died from the illness since then. At present, about 37 million people are living with HIV globally (WHO, 2018). This is a type of opportunistic infection, seen in people whose immune system have been severely damaged (such as people undergoing chemotherapy, or organ transplant recipients).

A type of skin cancer that was rare was recorded among men who have sex with men in New York and California that same year by the Center for disease control (CDC). In 1982, on the month of September the CDC called this disease AIDS.

Also, in 1983, Dr. Robert Gallo a member of National Institutes of Health (NIH) proposed that a retrovirus was likely the causative agent of AIDS (Gallo et al., 1984). In France, Professor Luc Montagnier of the Pasteur Institute reported a discovery of a retrovirus called Lymphadenopathy Associated Virus (LAV) that he said might be the cause of AIDS. These two men together announced that Gallo's HTLV-III retrovirus and Montagnier's LAV were identical and the causative agent of AIDS in June 1984 (Gallo et al., 1984).

2.2 Types Of HIV Virus

HIV belongs to the genus Lentivirus which is in the family of Retroviridae, and subfamily Orthoretrovirinae (Luciw, 1996). They are two groups of the HIV virus, Type 1 and Type 2(HIV-1, HIV-2) based on genetic characteristics and variances in the viral antigens. HIV-1 evolved from non- human primate immunodeficiency viruses from Central African chimpanzees (SIVcpz) and HIV-2 from West African sooty mangabeys (SIVsm). Globally, the major, earliest and most commonly referred to virus is HIV-1 and it is responsible for about 95% of all infections globally. The rather uncommon HIV-2 virus is concentrated in West Africa, but has been seen in other countries. It progresses very slowly more than HIV-1 and it is less infectious thereby resulting in fewer deaths (Grant et al., 2004).

I. Groups Within HIV-1

HIV-1 is further classified into four groups: M (the major group), N, O (the outlier group), and P. Among these, M is accountable for the many of the worldwide HIV epidemic. The three other groups O, N and P are quite uncommon. Group O represents up to 5% of Infections in several west and central African countries, and Group N and P have been rarely identified (Hemelaar, 2012).

II. Subtypes Within HIV-1 Group M

There are known to be at least nine genetically different subtypes of HIV-1 within group

They are different subtypes of the HIV-1 virus that differ genetically and they include , A, B, C, D, F, G, H, J and K. There are ‘Circulating recombinant form’ (CRFs) which are formed when different subtypes combine their genetic elements (Hamelaar, 2012). The greatest diversity of these subtypes is found in the Demographic Republic of Congo and Cameroon which is the area where the HIV-1 epidemic started. The pattern in which these subtypes are being spread geographically is rapidly changing due to the constant mixing in the population and the determining the pattern of transmission in many areas has also become more difficult (Fox et al., 2010).

Globally, an estimated 35 million people were infected with HIV in 2013 (UNAIDS, 2013). The number of new infections has been on a continuous decrease since 1999, and a number of 1.9 million newly infected persons was estimated for 2013. Sub- Saharan Africa houses about three quarter of HIV-infected persons, and also two-thirds of the new infections reported originate from this region. Africa is said to bear the greatest burden of HIV infection in the world. Heterosexual contacts are the major path of infection in Africa, and sex work and sexual violence has contributed greatly to the frequency of occurrence of the disease. Approximately one third of those who have HIV received ART in 2013 (UNAIDS, 2013). In Africa, all HIV-1 M subtypes and HIV-2 are circulating, the latter especially in Guinea-Bissau, Senegal, Cote d’ Ivoire and neighboring countries as well as in Angola and Mozambique.

2.3 Structure of HIV Virus

HIV is made up 15 types of vital protein, two strands of RNA, 15 and a few proteins from the last host cell it infected, and a lipid bilayer membrane surrounds it. The virus is able to infect the immune system cells because of the help of these molecules which force them to make copies of new virus.

2.4 Genome of HIV Virus

HIV-1 is made of double copies of unspliced, positive-sense single- stranded RNA that is non-covalently linked and is covered by a conical capsid made of the viral protein p24, characteristic of lentiviruses (Heng et al., 2011). The RNA constituent is 9749 nucleotides long (Sonigo et al., 1985) and has a 5’ c (Gppp poly (A) tail, and a lot of open reading frames (ORFs).

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Figure1.1: Structure of HIV

Source: WHO(2007)

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Figure 1.2 Genome of HIV Virus

Source: WHO(2007)

2.5 Immunology Of HIV Virus

As a retrovirus, the HIV attacks and damages the body’s natural defense system against disease and infection. It attacks and deactivates CD4+ T cells during the course of the infection. As stated by WHO (2010), HIV affects the immune system cells, impairing their function. Infection with the virus leads to a progressive decrease in the immune system function, leading to “immune deficiency” (Alimonti et al., 2003). When the immune system can no longer fight diseases, it becomes deficient. A healthy, uninfected person usually has 800-1200 CD4+ Tells per cubic millimeter of blood. But when infected with HIV, there is a decrease in the number of these cells.

2.6. HIV Pathogenesis of HIV Virus

HIV enters the body through intact mucous membranes, injured skin or mucosa and by parenteral inoculation. The virus first attaches to dendritic cells (e.g. Langerhans cells) or macrophages/monocytes when spread by sexual contact; HIV using CCR-5 (R5 viruses) as a co-receptor is then preferentially replicated (Demirkhanyan et al., 2013). HIV is taken up by macrophages and replicated (Paulis et al., 2013) in the mucosa. When the virus is exposed to the blood, the T helper cells becomes directly infected and there is a spread of R5 and X4 viruses with the aid of the CXC4 receptor as a co-receptor (Arrildt et al., 2012). Another epidemiologically significant route is snorting of drugs with epistaxis and parenteral administration of drugs.

The major routes of spread for the HIV virus are blood and the cerebrospinal and genital systems (ejaculate or vaginal secretion) (Bourlet et al., 2001). Intra-partum transmission has been said to occur during the 12th week of gestation, but transmission happens mostly (>90%) in the last trimester and mostly shortly before or during birth. HIV can be spread via breast milk (Arnaud et al., 1995). The virus can also be spread through breastfeeding due to the high level of viral load contained in the breast milk (Bourlet et al., 2001).

Transmission of HIV through blood or organ/bone transplant, is likely after about 5 – 6days after the donor has been infected. When the immune system begins to respond to the HIV virus after 3-6 weeks of infection, many infected persons begin to display clinical symptoms Levy(2007), which include a high body temperature, swelling of the lymph nodes, rashes, fatigue. These symptoms are also observed in other viral infections like Ebstein-Barr virus (EBV). After this early symptomatic phase, an asymptomatic phase follows and this phase can proceed for so many numbers of years.Virus titres of 105 – 109 are reached in the blood at the beginning of the infection, in rare cases up to 1014 genome copies/ml are observed. As a result, blood donations are highly contagious during this phase. During the asymptomatic phase, the viral load may decrease to <102 genome copies/ml or to undetectable levels. However, in this phase blood and seminal fluids of infected persons are still contagious. From day 11 post infection HIV RNA can be seen in blood (Lindback et al., 2000)

2.7 Opportunistic Infections

Infections that happen very often very serious in people who have deficient immune systems and this includes people infected with HIV. These infections are called opportunistic infections (OIs). These OIs were very common back in the days when they were fewer treatment options, but with the development of better treatment options OIs are able to be managed.However, OIs still develop in a lot of people infected with HIV because they may be ignorant of the fact that they have been exposed to the virus, and may not have commenced treatment, or may be experiencing treatment failure. The frequency of distribution of these opportunistic infections and clinical progression varies from one patient to another and from one country to country.

I. Candidiasis of Lungs, Bronchi, or Trachea

The causative cause of this disease is by contamination with a known (and normally harmless) fungus called Candida. Infection with Candida, affects the skin, mucous membrane and the nails throughout the body. Persons with HIV infection often have issues with Candida, especially in the mouth and vagina (CDC, 2008). When candidiasis infects the esophagus (swallowing tube) or the lower respiratory tract, that is when it is considered an opportunistic infection.

II. Tuberculosis (TB)

Mycobacterium tuberculosis is a bacterium which causes Tuberculosis (TB) infection. TB can be transmitted when an infected person sneezes or coughs (Ugochukwu, 2010). Infection of the lungs can occur when a person breathes in the bacteria, and symptoms may include cough, tiredness, weight loss, fever, and night sweats. Although the disease usually occurs in the lungs, various areas of the body are also affected, most often the larynx, lymph nodes, brain, kidneys, or bones (Bloom and Murray, 1992).

III. Invasive Cervical Cancer

This is a cancer that begins inside the cervix, which is the lower part of the uterus at the top of the vagina, and then extends (becomes invasive) to other areas of the body. This cancer can be prevented by having your care provider perform regular examinations of the cervix (Arminio et al, 1992; Mohar et al, 1992).

IV. Coccidioidomycosis

This disease is initiated by the fungus Coccidioides immitis. It most commonly developed when fungal spores are inhaled and this leads to a kind of pneumonia called desert fever. This infection commonly in hot and dry places like central America.



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evaluating hiv/malaria akwa-ibom state nigeria



Title: Evaluating the prevalence of HIV/Malaria co-infections in Uyo Akwa-Ibom State (Nigeria)