Author(s): Stephen ED Nsimba 1
amodiaquine; antimalarials; antiretrovirals; artemesinin-lumefantrine; chloroquine; combination therapy; malaria; sub-Saharan countries; sulfadoxine-pyrimethamine; Tanzania
Background & literature review
Malaria is a major public health and socioeconomic problem in sub-Saharan Africa including Tanzania. It is estimated that every year between 300 and 500 million clinical cases of malaria occur  , and approximately one million deaths result as a direct consequence of infection with Plasmodium falciparum  . Malaria-related morbidity and mortality are more prevalent in children  .
Furthermore, malaria infection during pregnancy is a major public health problem in tropical and subtropical regions throughout the world. Pregnant women constitute the second main adult risk group for malaria and 80% of deaths due to malaria in Africa occur in pregnant women and children under 5 years of age  . It is estimated that in Africa over 30 million women become pregnant annually and most of these women live in areas of stable malaria transmission  .
Although human malaria is caused by four parasite species of Plasmodium , most infections and severe morbidity and mortality are caused by P. falciparum , which has been shown to be common in pregnant than nonpregnant women and to have substantial adverse effects on pregnancy outcomes including low birth weight, fetal distress, premature labor, intrauterine growth retardation and an increased number of still births, miscarriages and neonatal deaths. Acute P. falciparum malaria during pregnancy is considered to be particularly dangerous, since the underlying anemia can be dramatically exacerbated by red blood cell destruction. However, malaria is commonly asymptomatic during pregnancy and is not always diagnosed. A clinical trial in Kenya reported that presumptive treatment of all pregnant women in endemic malarial areas with only two doses of sulfadoxine/pyrimethamine (SP) reduced the incidence of anemia among first-time mothers by 39%  .
The malaria situation is deteriorating every year in Tanzania  , as evidenced by widespread P. falciparum resistance to chloroquine (CQ)  , loss of efficacy due to resistance against SP, and increasing malaria-related morbidity and mortality  . Resistance to CQ and SP has severely compromised effective treatment and malaria control programs in most sub-Saharan countries. Furthermore, the role of HIV in the epidemiology of malaria in pregnancy needs to be considered as an estimated 27 million people are living with HIV/AIDS and 55% of all adult HIV infection is among women of reproductive age. There is also a geographical overlap between malaria and HIV, and 44% of the 43 sub-Saharan African countries with malaria have HIV seroprevalence of [greater than or equal]10% among antenatal clinic (ANC) attendees [6,7] .
Despite these drawbacks and the phasing out of both CQ and SP for clinical management of uncomplicated malaria, SP is still used for intermittent presumptive prophylactic treatment (PT) for pregnant women and infants in mainland Tanzania [6-9,103] . In endemic areas of Tanzania and other sub-Saharan countries, early diagnosis and prompt effective treatment including the use of long-lasting insecticide-treated bed nets (ITNs), remain the most effective malaria control strategies [10,11] . However, PT with SP and ITNs use must go hand in...