A Novel Regimen to Prevent Malaria and STI in Pregnant Women With HIV

The World Health Organization (WHO) recommends malaria prophylaxis for all pregnant women
living in endemic areas in order to reduce maternal anemia, low birth weight and perinatal
mortality by 25-45%. The most commonly used regimen is intermittently dosed
sulfadoxine-pyrimethamine (SP).Unfortunately, SP prophylaxis is contraindicated for
HIV-infected pregnant women since co-administration with TMPS (trimethoprim-sulfamethoxazole)
causes serious adverse events. TMPS (Bactrim or Cotrimoxazole) is an effective,
well-tolerated, low-cost antibiotic that is used as prophylaxis in HIV-patients with low CD4
counts. It has anti-malarial activity with prophylactic efficacy that is comparable to SP
(30-90%). Daily TMPS is recommended as malaria prophylaxis in pregnant women with HIV in many
African countries (including Cameroon) but malaria infection rates are high even when
medication compliance is excellent; thus, new and improved options are urgently needed.
Azithromycin (AZ) is a macrolide antibiotic with activity against malaria, a good safety
profile in pregnancy and proven utility as a part of combination malaria prevention regimens
(such as SP-AZ). It also has activity against sexually transmitted infections (STI) and
perinatal pathogens, including chlamydia (CT), gonorrhea (GC), syphilis and GBS
(Streptococcus agalactiae or Group B Streptococcus), a potential but understudied contributor
to high rates of newborn sepsis and death in Africa. SP-AZ prophylaxis in HIV-uninfected
pregnant women has been reported to reduce prevalence of low birth weight (RR 0.74, 95%
confidence interval (CI) 0.6-0.9) and preterm delivery (RR 0.66, 95% CI 0.48-0.91) compared
to SP alone.

Thus, the central hypothesis is that a TMPS-AZ combination will be more effective than
standard TMPS malaria prophylaxis in pregnant women with HIV, and that it will also decrease
STI coinfection. Investigators plan a test-of-concept of the central hypothesis by conducting
a double blinded, Phase II randomized controlled trial (RCT).

Inclusion Criteria:

- Confirmed HIV-infection (documented in medical record)

- Age ≥16 years

- Confirmed pregnancy, <28 weeks estimated gestational age (by best obstetric estimate
which may include ultrasound or fundal height and LMP)

- Live singleton pregnancy

- Receiving prenatal care at Mboppi Hospital or Mutengene Hospital

- Plan to receive follow up prenatal care and deliver at study facility

- Capable of providing written informed consent

- Able and agree to come to facility for febrile episodes or acute illness during
pregnancy (with reimbursement of transportation costs).

- Agree to avoid antimalarial medications outside of study protocol.

Exclusion Criteria:

- Severe anemia (last hemoglobin <6)

- History of severe adverse reaction to co-trimoxazole or azithromycin

- Active medical problem requiring inpatient evaluation at the time of screening

- Intention of moving far away from the facility during pregnancy or not likely to
return for follow up care or delivery

- Signs or symptoms of early or active labor

- History of severe cardiac disease (including congestive heart failure, severe valvular
disease or arrhythmias).