The Effectiveness Of Co-trimoxazole Prophylaxis And Antiretroviral Therapy In Reducing The Morbidity Of Malaria In HIV/AIDS-Infected Adults In Sub-Saharan Africa

Chapter 1: Introduction

To investigate if the wider use of co-trimoxazole prophylaxis and antiretroviral therapy can substantially reduce the morbidity of malaria in HIV/AIDS infected adults in sub-Saharan African region.

Chapter 1: Introduction

It has become obvious that the resource-deprived regions of the world, particularly the developing countries like Sub-Saharan Africa carries the burden of the Human Immunodeficiency Virus (HIV) (Lau & Muula, 2004). Additionally, the possible pathophysiological interactions between HIV and tropical pathogens like Plasmodium falciparum raising the serious concern for healthcare providers (Alemu et al., 2013). Plasmodium falciparum is the major species responsible for 85% of malaria cases (WHO, 2015). Previous researches provide sufficient evidences claiming the higher prevalence of malaria among HIV patients in the region.  The malarial incidence in AIDS patients is inversely correlated with the CD4 cell count (Van geertruyden, 2014; Idemyor., 2015).

The use of co-trimoxazole prophylaxis is currently recommended to prevent the opportunistic infections like Toxoplasmosis and Pneumocystis in adults living with HIV/AIDS (WHO, 2015). Some studies showed the importance of co-trimoxazole prophylaxis along with the ART to decrease the prevalence of malaria in HIV-infected adults. So, it has become the point of interest to investigate the effectiveness of co-trimoxazole and ART in incidence of malaria in HIV-infected adults of Sub-Saharan Africa (Lawn et al., 2008; Harouna., 2015).

Aim and Objectives

The research paper aims to investigate whether the antiretroviral treatment (ART) and co-trimoxazole prophylaxis reduces the morbidity of malaria in adults infected with HIV/AIDS in the sub-Saharan Africa. The following are the identified objectives to guide the question.

To investigate if co-trimoxazole prophylaxes decrease the prevalence of malaria in HIV/AIDS infected adults.

To investigate if the wider usage of co-trimoxazole prophylaxis and ARVs therapy substantially reduce the morbidity from malaria in HIV infected patients.

To investigate if the clinical interventions in the treatment of malaria in adults with HIV/AIDS reduce the morbidity and mortality rates from adults suffering from malaria and infected with HIV/AIDS.

This chapter discusses the framework of the study by focusing on the background to the problem as well as purpose and objectives of the study. This chapter highlights the importance of the study and assumptions held by the researcher. Chapter 2 will focus on the review of related literature.

Chapter 2: Literature review

According to Bhatt et al., (2015) annually about 0.7 to 2.7 million people die from malaria, and more than 60% of them are from Sub-Saharan African countries. At such dreadful rate, the mortality will be estimated to get doubled by 2020, if effective control measures are not employed.  Clinical manifestations of malaria mainly impair the cognitive functions and behaviour and produce a huge loss of resources in both tangible and intangibles form to the society (Ceesay et al., 2015).

Chapter 2: Literature review

The link between malaria and HIV/AIDS

According to Fehintola et al., (2016), the incidence of malaria and HIV/AIDS is very high in geographic regions like sub-tropical and tropical districts of the world, especially in sub-Saharan Africa. Both of the diseases mainly affect the poorest sections of the population, which might be more helpless against the disease because of rare healthcare facilities, knowledge etc (Achan et al., 2012). Ezeamama et al., (2014) reported that geographical overlapping of HIV and malaria is creating a serious mess for the government and healthcare agencies. Vamvaka et al., (2015) reported that HIV infection causes progressive cellular immunosuppression which is associated with the failure to prevent any infection. Furthermore, Kublin & Steketee (2015) argue that in spite of the fact that malaria can increase the viral replication in the short term; the main concern is that the increment connected with malaria in viral replication could speed up the HIV/AIDS progression.

Morbidity of Malaria in adults infected with HIV/AIDS in sub-Saharan Africa

According to Zaba et al., (2013) the HIV/AIDS and malaria are two of the most important health problems in the world today. Both malaria and HIV/AIDS causes more than 4 million deaths a year, especially in children and young adults.

Clinical Interventions in the treatment of Malaria in Adults with HIV/AIDS

Malaria can be prevented by taking various precautions like avoiding the growth of larvae, cleanliness etc. It is entirely treatable disease with lot of treatment options. The use of anti-malarial medicines is highly recommended for HIV/AIDS infected adults with malaria (WHO, 2016). HIV/AIDS and malaria are common infections in Africa, and cause substantial morbidity and mortality and yet co-trimoxazole prophylaxis is a readily available, effective intervention for people with HIV infection in Africa and the world at large (Mermin et al., 2014).

Parikh et al., (2013) reported that by prescribing the right drug at appropriate dose the risk of mortalities can be minimized. The prescription of non effective dosage or sub-therapeutic dose may cause recurrence of the infection. It may also lead to the rise in drug resistance. Adherence of the patient with prescription or drug regime can helps in effective treatment and diminishes the rate of mortality (Van geertruyden, 2014).

A joint United Nations programme on HIV/AIDS recommended that all infected adults should be treated with Co-trimoxazole as it reduces the morbidity irrespective of any clinical disease stage or CD4 cell count (UNAIDS, 2011, Gupta et al., 2014).

The link between malaria and HIV/AIDS

Drawing from the discussion given above, it can be assumed that the morbidity of   malaria in HIV/AIDS cases is a growing concern not only in poor regions of the sub Saharan Africa but worldwide, hence the use of anti – malaria medicines is highly recommended. The next chapter describes the research methodology and the research design that was employed in the study.

Chapter 3: Methodology

Research strategy

The research strategy in this dissertation was to conduct a systematic literature review of contemporary evidence (within a time frame) to explore the role of clinical intervention. The review of secondary data in systematic review widely establishes the research strategy in healthcare and medicine (Taylor, Bogdan & DeVault, 2015).

The literature search strategy had three stages which included the electronic search, manual search and tracking references. The electronic search was done using the following search engines: Pub Med, Cinahl, Medline, Google Scholar, Psycho- Info and King’s Fund (Table 1) to ensure the full coverage of relevant published data.

Search words

The search used Pub Med, Embase, Cochrane Central Register of Controlled Trials and the International Standard Randomized Controlled trials using PICO research framework for the following terms: Co-trimoxazole, Anti-retroviral therapy, HIV/AIDS, Malaria and Sub-Saharan Africa (Table 1).  These keywords were applied in different combinations to specify the outcome of every search. The present study was limited to the time frame of January, 2004 to June, 2016.

Table 1: Search terms and health databases sources

Search words	Method	Resources
Infected HIV/AIDS	All of the Keywords were used in different combinations on each database	Pub Med
Co-trimoxazole prophylaxis	Cinahl
Anti- retroviral therapy	Medline
Sub Saharan Africa	Embase
Malaria	Google scholar
Morbidity	Pyscho’s Fund

Inclusion/Exclusion criteria

The initial search of selected databases provided a large number of articles, however, a closer analysis of their title and abstract revelled that many of those articles were too broad or not fully relevant to the research objectives. The following inclusion and exclusion criteria have used in present study to select the relevant studies (Table 2).

Table 2: Inclusion and exclusion criteria of the study

Criteria of Inclusion	Criteria of Exclusion
All research studies discussing the ART and co-trimoxazole prophylaxis in lowering the morbidity of malaria in adults infected with HIV/AIDS.	All studies irrelevant to the research topic.
Latest publications (From Jan, 2004 to June, 2016)	Older publications to rule out the repetitions.
Authentic resources like peer review papers and books	All sort of literature which is not credible will not be included.
Studies published in English	Studies in any other language will not be included.
Articles from other credible sources that talk of implementations, barriers and compliance of the anti malaria regimes.	Studies involving children

The next chapter will focus on the data presentation, data analysis and interpretation in relation to the objectives outlined in chapter 1.

Chapter 4: Results, data presentation, analysis and interpretation.

This chapter focuses on the presentation, analysis and interpretation of the data reviewed from the articles selected. The main focus of this chapter is to present the findings in detail. It is important to reflect on the purpose of the study which is to investigate if the wider use of co-trimoxazole prophylaxis and antiretroviral therapy can substantially reduce the morbidity of malaria in HIV/AIDS infected adults in sub-Saharan African region.

Morbidity of Malaria in adults infected with HIV/AIDS in sub-Saharan Africa

Results

As per the inclusion and exclusion criteria, the number of paper relevant to our study is mentioned in Table 3 and Table 4.

Table 3: Number of paper on various databases

Resource	Number of paper
Pub Med	385
Cinahl Plus	831
Google scholar	331
Cochrane	37

On narrowing the research with time frame, a total of 90 papers were selected. On close examination of these articles, it has been observed that most of the articles did not meet the inclusion criteria as they were studies carried for other age groups (children and pregnant women with HIV/AIDS) and were not relevant to the research topic and so about 31 articles (Table 4) were selected and eventually 6 were identified for the review project (Table 5). The selected articles were analysed using the CASP appraisal tool which is a principle tool to review academic articles.  This article review tool provides various parameters and yardsticks on the basis of which a reviewer can analyse and assess the various strength and weaknesses of a scholarly work. A CASP is a ten question guide retrieved from the internet (Google) as a Critical Appraisal skills programme.

Table 4: Number of relevant papers selected

Within the last 10 years	Database Searched: Pub Med	Database Searched: Cinahl	Database Searched: e.g. Google scholar	Database; Cochrane	Total
Total after limits applied	3	11	12	5	31

Table 5: Studies selected for systematic review

Anglaret X & Eholie S (2008)	Prophylaxis with co-trimoxazole for HIV infected adults in Africa. BMJ. 337. A304.
Harries A. D, Lawn S.D, Suthar A. B, Granich R, (2015)	Benefits of combined preventive therapy with co-trimoxazole and isoniazid in adults living with HIV: time to consider a fixed-dose, single tablet co formulation. Lancet Infect Dis.1492-1496.
Mermin J. Lule J. Ekwaru J.P, Malamba S, Downing R, Ransom R, Kaharuza F, Culver D, Kizito F, Bunnell R, Kigozi A, Nakanjako D, Wafula W, Quick R, Lancet, (2006)	Effect of co-trimoxazole prophylaxis, antiretroviral therapy, and insecticide-treated bednets on the frequency of malaria in HIV-1-infected adults in Uganda: a prospective cohort study. Lancet. 367 (9518). p. 1256-61.
Mermin J, Lule J, Ekwaru J.P, Malamba S, Downing R, Ransom R, Kaharuza F, Culver D, Kizito F, Bunnell R, Kigozi A, Nakanjako D, Wafula W, Quick R, (2004)	Effect of co-trimoxazole prophylaxis on morbidity, mortality, CD4-cell count, and viral load in HIV infection in rural Uganda. Lancet. 364 (9443). p. 1428-34.
Nunn A.J, Mwamba P.B, Chintu C, Crook A.M, Darbyshire J.H, Ahmed Y, Zumla A.I, (2011)	Randomised, placebo-controlled trial to evaluate co-trimoxazole to reduce mortality and morbidity in HIV-infected post-natal women in Zambia (TOPAZ). Trop Med Int Health. 16 (4). p. 518-26.
Walker A.S, Ford D, Gilks CF, Munderi P, Ssali F, Reid A, Katabira E, Grosskurth H, Mugyenyi P, Hakim J, Darbyshire J.H, Gibb D.M, Babiker A.G, (2010)	Daily co-trimoxazole prophylaxis in severely immunosuppressed HIV-infected adults in Africa started on combination antiretroviral therapy: an observational analysis of the DART cohort. Lancet. 375 (9722). p. 1278-86.

Anglaret & Eholie (2008) reported the effectiveness of co-trimoxazole in the adult HIV infection treatment in peculiar cases where resistance of bacteria is extremely high. The study further concluded that the medication lessens the mortality in HIV patients in situations where resistance of bacteria might be high. 

Walker et al, (2010) reported that in Sub-Saharan Africa, mortality from HIV infection (untreated) can be reduced with proper clinical treatment of Co-trimoxazole prophylaxis, however, there is little evidence about the antiretroviral combination therapy, hence Walker et al, (2010) found it important to explore the effectiveness of a combination of antiretroviral therapy (ART) in adults. Furthermore, Walker et al., postulated that reinforcement of standard guidelines of WHO required for co-trimoxazole prophylaxis provision for all adults starting combination ART for at least 72 weeks in sub-Saharan Africa.

Mermin et al., (2004) in this article has briefly but explicitly stated the context and purpose of this article, that the sub-Saharan Africa is a part of the world where bacterial resistance is reported to be extremely high in reported cases of co-trimoxazole. This is very much aligned to the title of the article. The aim of the researchers in this work was to assess effects of co-trimoxazole prophylaxis on mortality, morbidity, viral load and CD4-cell count among HIV infected patients in the sub-Saharan rural Uganda. The research purpose is highly rationalised by the arguments of Mermin et al (2004), regarding the high prevalence of bacterial resistance in the area.

Clinical Interventions in the treatment of Malaria in Adults with HIV/AIDS

Mermin et al, (2004) found that proper clinical intervention with co-trimoxazole prophylaxis (daily dosage) was clearly and strongly linked with abridged mortality and morbidity and it also has valuable effects on viral load and CD4-cell count.  

Mermin et al, (2006), in describing the context and background of malaria and HIV-1, says that they are very common infections and cause considerable mortality and morbidity in Africa. With an increased incidence of malaria, and more severe diseases, HIV infection has been related.

In this article Mermin et al, (2006) found that insecticide-treated bed nets and antiretroviral in combination of co-trimoxazole therapy, reduced the malaria frequency substantially in HIV affected adults. 

Nunn et al, (2011) have described the role of antibacterial prophylaxis (prophylactic trimethoprim-sulphamethoxazole), in dropping mortality and morbidity in post-natal women in southern Africa (sub-Saharan region). In this study, female HIV patients’ participants (cotton arm) were given a clinical intervention of daily co-trimoxazole of coordinated placebo in selected facilities at a teaching hospital in Zambia. Nunn et al, (2011), concluded that there was no evidence with poor follow-up rate that hospital admission or mortality or rates are reduced by co-trimoxazole prophylaxis, although in the cotton arm, fewer symptoms were reported hence it’s a well-tolerated and safe option. 

Harries et al., (2015) in this article has concluded that along with pyridoxine (vitamin B6), isoniazid and co-trimoxazole ought to be mixed into a single pill and given in fixed-dose to mitigate morbidity as a clinical intervention in reducing the morbidity of malaria in adults infected with HIV/AIDS.

This chapter has focused on data presentation, analysis and interpretation in relation to the identified objectives. The main findings will be discussed in chapter 5.

Chapter 5: Discussion

Introduction

This chapter focuses on explaining of the key findings of the study. Chapter 4 had presented the findings of the reviewed literature. This chapter will critically appraise the strength and limitations of the study.

The broad purpose of the systematic review was to verify the effectiveness of clinical intervention of co-trimoxazole prophylaxis and antiretroviral therapy to substantially reduce the morbidity of malaria in HIV/AIDS infected adults in sub-Saharan region. Evidences described the effectiveness of clinical intervention of co-trimoxazole prophylaxis and antiretroviral therapy towards the reduction of malaria morbidity in HIV/AIDS infected adults. The objectives of the study were:

To investigate if co-trimoxazole prophylaxes decrease the prevalence of malaria in HIV/AIDS infected adults.

Mermin et al, (2006) found that insecticide-treated bed nets and antiretroviral in combination of co-trimoxazole therapy, reduced the malaria frequency substantially in HIV affected adults. All the other six articles were in agreement with the findings that co-trimoxazole prophylaxes decrease the prevalence of malaria in HIV/AIDS infected adults.

Chapter 3: Methodology

Nunn et al, (2011), presented the findings showing that in the combined events, the results between the two treatment ‘arms’ had no significant differences, over a range of symptoms but a decrease in morbidity was found. Some evidence found showed abridged mortality rate in peculiar cases. Hence, the results showed a lot of variability in the prevalence rates of adherence / non-adherence to treatment. Amongst the factors contributing to treatment adherence, the authors have highlighted greater understanding of the disease, severity of symptoms, dose gratuity of drugs, use of pictorial on the packaging of the antimalarials, and good guidance of health professionals in relation to drug and its effects. In relation to non-adherence to treatment, the following factors were also highlighted: forgetfulness, symptom improvement, inaccessibility, side effects of antimalarial, and lack of guidance and/or incorrect guidance on drugs made by the health professional.

Walker et al, (2010) extensively made use of various previous studies and concluded that in the sub- Saharan region, malaria prevalence in HIV/AIDS adults can be substantially reduced with proper clinical treatment of co-trimoxazole prophylaxis although he differed in opinion on the effect of combined co trimoxazole and antiretroviral therapy (ART).

In all six articles, the authors are in agreement that the use of co –trimoxazole prophylaxis in the treatment of malaria in HIV/AIDS infected adults, may reduce the prevalence, in the African region. Yet, there is still a grey area to whether a combined usage of co-trimoxazole and ART is effective in reducing morbidity and mortality rates. Also, the issue of non-adherence to treatment is repeatedly mentioned by Nunn et al, (2011) and Walker et al (2010), thus leading the author to present it as the major recommendations for improvement.

To investigate if the wider usage of co-trimoxazole prophylaxis and ARVs therapy substantially reduce the morbidity from malaria in HIV infected patients.

From the literature reviewed, it can be concluded that the clinical interventions and the effect of antiretroviral treatment (ART) and co-trimoxazole prophylaxis certainly reduce the morbidity of malaria in adults infected with HIV/AIDS in the African continent (Harries et al, 2015). ART is the intervention, needed for reducing the morbidity and mortality rates in adult HIV patients, although, in poor, resource-limited and undeveloped areas, ART is reported sluggishly to have an effect with considerable early mortality and morbidity rates (Harries et al, 2015). Mermin et al, (2004) found at the end of the study that proper clinical intervention with co-trimoxazole prophylaxis (daily dosage) was clearly and strongly linked with abridged mortality and morbidity and it also has valuable effects on viral load and CD4-cell count. Mermin et al, (2006) brought up the comparison that insecticide- treated bed nets and antiretroviral in combination of co-trimoxazole therapy reduced morbidity in HIV/AIDS infected adults with malaria.

Walker et al, (2010) extensively made use of various previous studies and concluded that in Africa, malaria prevalence in HIV/AIDS adults can be substantially reduced with proper clinical treatment of co-trimoxazole prophylaxis although he differed in opinion on the effect of the combined co trimoxazole and antiretroviral therapy (ART), thus creating room for further studies of the grey area.

Anglaret X & Eholie S (2008) et al, (2008), concluded that the wider usage of co-trimoxazole prophylaxis reduce morbidity amongst HIV/AIDS adults infected with malaria, even in situations where resistance of bacteria might be high.

Generally all the six authors agreed that wider usage of co-trimoxazole prophylaxis and ARVs therapy substantially reduce the morbidity from malaria in HIV infected patients. Walker et al (2010) differed in opinion on the effect of the combined co-trimoxazole and antiretroviral therapy (ART), thus it creates yet another grey area for further studies.

To investigate if the clinical interventions in the treatment of malaria in adults with HIV/AIDS reduce the morbidity and mortality rates from adults suffering from malaria and infected with HIV/AIDS.

All the six authors of the reviewed literature agree with the findings that clinical interventions in the treatment of malaria in adults with HIV/AIDS reduce the morbidity and mortality rates of malaria in HIV infected patients. Harries et al, (2015) concluded that along with pyridoxine (vitamin B6), isoniazid and co-trimoxazole ought to be mixed into a single pill and given in fixed-dose to mitigate morbidity as a clinical intervention in reducing the morbidity of malaria in adults infected with HIV/AIDS.

Walker et al (2010) has concluded to reinforce and challenge the standard guidelines for World Health Organisation (WHO) and offered robust incentive for co-trimoxazole prophylaxis provision for all adults starting a combination ART for at least 72 weeks in sub-Saharan Africa.

Mermin et al, (2004) strongly linked proper clinical intervention of co trimoxazole prophylaxis to an abridged mortality and morbidity rates in adults infected with HIV/AIDS and suffering from the chronic malaria. The results by Mermin et al, (2004) are very critical for this systematic review, as substantial evidence established the high effectiveness of clinical intervention in reducing the morbidity and mortality rates of malaria in adults infected with HIV/AIDS in the Sub Saharan Africa.

All authors appear to be saying the same message that compliance to the clinical intervention of the treatment of malaria in adults with HIV/AIDS reduces the morbidity and mortality rates. One weakness identified by the authors is the non – compliance by patients to clinical intervention which may have affected the results and outcome of most studies done to date, Harries et al, (2015). Compliance to medication and close monitoring by the HIV/AIDS team is important in order to get the best results of clinical interventions in the treatment of malaria and HIV/AIDS.

In the studies analysed above they have cross- examined the effect of clinical interventions and the use of ARV therapy in the treatment of malaria in adults with HIV/AIDS and have concluded that clinical interventions reduce the morbidity from malaria in HIV infected adults.

Models of public health

As a public health practitioner, it’s important to offer sound advice and up to date information based on current evidence in order to educate patients falling into this category globally on how clinical interventions of co-trimoxazole prophylaxis and the use of ARV therapy is effective in the treatment of malaria in adults with HIV/AIDS.

Three public health theories which focus on community drug non-compliance and useful to behaviour change in this project have been identified. According to the US Centres for Disease Control and Prevention of Chronic Disease and Health Promotion (2002) the following models have been identified;

The Health Belief model

For men and women to adopt the recommended physical activity behaviour, there is need to educate them on the importance of compliance to treatment so that their perception of the threat of malaria within an HIV/AIDS infected patient outweigh their perceived barriers to action. A nurse manager of HIV/AIDS infection is recommended to take charge of this activity Bethesda (1995). The Health Belief model will be effective to apply to adults infected with HIV/AIDS to adopt recommended physical activity behaviours being monitored by the nurse manager of HIV infection.

The Information Processing model

The model has an impact through persuasive communication, Bethesda (1995).It is mediated by three phases of message processing, that is attention to the message, comprehension of the content, and acceptance of the content, Bethesda (1995). Men and women can have correct, up to date information and renewed awareness on the effect of clinical interventions of co-trimoxazole prophylaxis on reducing morbidity of malaria in adults infected with HIV/AIDS on the dangers of engaging in drugs through the information model. In this study they can get helpful information on why it is important to be fully compliant to clinical intervention and antiretroviral therapy.

The Community Organizational model

The Community organizational model is ideal as it emphasizes on the active participation of the target group in identifying key health issues and strategies to address them. The model empowers the communities to improve their health thus making them participate in decision making.

Strengths

Mermin et al., (2004): Walker et al., (2010): Anglaret & Eholie (2008): Nunn et al., (2011): Harries et al., (2015) agree with the findings that clinical interventions in the treatment of malaria in adults with HIV/AIDS reduce the morbidity and mortality rates of malaria in HIV infected patients. The effectiveness of using co-trimoxazole prophylaxis and antiretroviral therapy has not been disputed in all reviewed articles. All articles reviewed in this study had a common background of utilising a range of previous studies that provided a sound conceptual and theoretical basis to study. The use of various previous studies is a positive aspect of this study.

Limitations

Non treatment adherence has been identifies as one limiting factor towards compliance to clinical medication in some instances, hence this calls for close monitoring of patients by the HIV nurse practitioner who would understand the background and importance of medication compliance in the treatment of malaria morbidity in HIV/AIDS patients. There is need for further interventions targeting the wider usage of co-trimoxazole prophylaxis and ARVs therapy.

Also, the limitation for using this kind of information is that the information constantly changes with new sites appearing every year and it is highly encouraged for policy makers to set global standard guidelines to benefit poor nations; The WHO and its Care Quality Commissions (CQC) to be seen vigilant with their inspectorate and Quality Assurance.

Chapter 6: Conclusion

In its quest to explore whether the clinical interventions and the effect of antiretroviral treatment (ART) and Co-trimoxazole prophylaxis reduce the morbidity of malaria in adults infected with HIV/AIDS in the Sub Saharan, this systematic review has concluded that the clinical interventions and the effect of antiretroviral treatment (ART) and Co-trimoxazole prophylaxis certainly reduce the morbidity of malaria in adults infected with HIV/AIDS in the Sub Saharan Africa.

This systematic review now further recommends launching an inquiry to assess this effectiveness in male and female patient separately to enable the better and holistic understanding of the issue. The findings of this review are critical in establishing the high effectiveness of basic clinical intervention in extreme cases like HIV care.

However, the compliance amongst patients to clinical medication in sub-Saharan Africa is very low. Hence within a public health system, lack of adherence to antiretroviral therapy must be considered as a problem of inefficiency that prevents the achievement of clinical effectiveness that can be achieved with the resources available for the treatment of HIV infection. For all this complexity of clinical management, it might be interesting to expose individual monitoring of patients, hospitalized by the nurse manager of HIV infection. Research for this purpose will contribute to the knowledge of the magnitude of the problem of non-adherence to treatment of malaria in those countries, especially if the authors worry in developing them with similar methodological designs.

Brief recommendations for practice

The results are precise as findings indicate that the wider use of co-trimoxazole prophylaxis and antiretroviral therapy can substantially reduce the morbidity of malaria in HIV/AIDS infected adults in sub-Saharan African region and indeed in the rest of the world. In summary, clinical interventions in the treatment of malaria in adults with HIV/AIDS is significantly associated with an improvement in overall wellbeing of persons infected with HIV/AIDS globally. However this is limited by the rate of adherence/non-adherence by individual victims. The authors used more than one method of measuring adherence and self-narrative was present in almost all studies. The definition of adherence was associated with complete follow – up of treatment, confirmed by counting medications. The results showed a lot of variability in the prevalence rates of adherence / non-adherence. In relation to non-adherence to treatment the following factors were highlighted, forgetfulness, symptom improvement, inaccessibility, side effects of antimalarial, and lack of guidance and / or incorrect guidance on drugs made by the health professional. Lack of adherence to antiretroviral therapy must be considered as a problem of inefficiency that prevents achieve clinical effectiveness that can be achieved with the resources available for the treatment of HIV infection (Walker et. al 2010), hence there is need to implement such programmes with sufficient human resources and expertise. Use of interactive individual groups is recommended to engage with the patients. Old policies need to be renewed with up to date policies, which address activity. Lastly, the interventions need to be internationally structured and not to translate only to sub-Saharan Africa.

Brief suggestions of theory and practices

A coordinated approach from the Public Health Services, Health Promotion Services, staff and patients should be put in place. Staff development workshops, peer education programs and policy development should be considered as strategies to bring and increase awareness of the importance of the use of co-trimoxazole prophylaxis and ART to the recipients. Results showed a lot of variability in the prevalence rates of adherence / non-adherence. Among the factors contributing to treatment adherence, highlighted greater understanding of the disease, severity of symptoms, dose gratuity of drugs, use of pictorial on the packaging of anti-malarial figures, and good guidance of health professionals in relation to drug and its effects (Walker et al, 2010). This systematic review does further recommend launching an inquiry to assess this effectiveness in male and female patients separately so that they can holistically understand the issue (Walker et al, 2010).

Barriers to implementing the findings

In relation to non-adherence to treatment the following factors are highlighted, forgetfulness, symptom improvement, inaccessibility, side effects of antimalarial, and lack of guidance and / or incorrect guidance on drugs made by the health professional. The systematic study of research has enabled the current status of the publications   on adherence to malaria treatment and has found that there are gaps to be filled with future research. The writer suggests that studies are to be conducted in the sense to verify the adherence prevalence of malaria globally, considering that few publications have been made so far. Research for this purpose will contribute to the knowledge of the magnitude of the problem of non-adherence to treatment of malaria in those countries. This paper suggests avenues for further research.

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