OPTImizing Malaria And HIV Treatment in a Shifting Landscape in Africa

CLHIV will be maintained on a dolutegravir (DTG) based regimen for >2 weeks prior to enrolment to ensure steady state. All children in Busia (HIV-infected and HIV-uninfected) will be enrolled and then randomized to receive either artemether- lumefantrine (AL) or artesunate-amodiaquine (AS-AQ) for each episode of malaria which occurs over longitudinal follow-up in year one. During year 1, they will continue to receive the same antimalarial each time they are treated for uncomplicated malaria. In year two, those children randomized to the AL arm will begin to receive an alternating regimen for each subsequent malaria episode (AS-AQ, then AL, then AS-AQ, etc..). If local/national guidelines in Uganda for malaria change during the course of the study, the treatment arms will be altered as applicable. Aim 1: To what extent does DTG impact, BMI, body composition and metabolic changes? Aims 2 and 3: Are there critical drug-drug interactions between DTG and first line artemisinin-based combination therapies (ACTs)? Do these changes impact HIV and malaria outcomes? What is the status of ACT resistance and its relationship to PK exposure?

MALARIA CASE DEFINITION:

Uncomplicated malaria (all of the following)

• Fever (≥ 37.5ºC axillary) or history of fever in the previous 24 hours
• Positive thick blood smear (any parasitemia)
• Absence of severe malaria Severe malaria
• Evidence of severe malaria as per WHO criteria

Inclusion criteria

• Agreement to come to the clinic for all follow-up evaluations
• Provision of informed consent and assent (as appropriate)
• Residency within approximately 30 km of the study clinic
• Negative blood smear for malaria (all sites)
• For Children and adolescents living with HIV

• Confirmed HIV infection
• On DTG-based regimen for ≥14 days
• For HIV-uninfected children - documentation of HIV-negative status by at least 1 assay

Exclusion criteria

• Significant comorbidities such as malignancy, active TB, chronic/active hepatitis B/C, diabetes, severe acute malnutrition, mitochondrial disorders
• Receipt of known CYP interacting drugs at enrolment (except HAART) - see list of disallowed medications
• Anemia defined by hemocue (Hb < 7.0) at the time of enrolment
• Signs of uncomplicated or severe malaria at the time of enrollment
• Prior intolerance to AL or AS-AQ (for those in Busia only)
• Pregnancy at enrolment (testing done at enrollment for all those of child-bearing age)
• Concurrent enrolment in another research study