Evaluation of Alternative Antimalarial Drugs for Malaria in Pregnancy (MiPPAD)

Evaluation of the Safety and Efficacy of Mefloquine as Intermittent Preventive Treatment of Malaria in Pregnancy

Barcelona Centre for International Health Research, Institute of Tropical Medicine, University of Tuebingen, Institut de Recherche pour le Developpement, Université d'Abomey-Calavi, Albert Schweitzer Hospital, Kenya Medical Research Institute, Ifakara Health Institute, Centro de Investigacao em Saude de Manhica, Vienna School of Clinical Research (VSCR), Austria., Centers for Disease Control and Prevention, Malaria in Pregnancy Consortium

The study aims at comparing the safety, tolerability and efficacy of Mefloquine (MQ) to Sulfadoxine-Pyrimethamine (SP) as Interment Preventive Treatment in pregnancy (IPTp) for the prevention of malaria effects on the mother and her infant.

The current recommendation by the World Health Organization (WHO) to prevent malaria infection in pregnancy in areas of stable malaria transmission relies on: Prompt and effective case management of malaria illness The use of intermittent preventive treatment (IPTp) with at least 2 treatment doses of sulfadoxine-pyrimethamine (SP) and The use of insecticide treated nets (ITNs) However, the spread of parasite resistance to SP, particularly in eastern Africa, and the significant overlap in some regions of malaria transmission and high prevalence of HIV infection, have raised concerns about the medium and long-term use of SP for IPTp. HIV infection increases susceptibility to malaria and may reduce the efficacy of interventions. The evaluation of alternative antimalarials for IPTp is thus urgently needed also involving HIV infected women. Of all the current available alternative antimalarial drugs, mefloquine (MQ) is the one that offers the most comparative advantages to SP. A randomized multicenter trial will be conducted in 4 sites in Africa (Benin, Gabon, Tanzania and Mozambique) in order to compare the safety and efficacy of SP versus MQ as IPTp in the context of ITNs. In addition, MQ tolerability will be also evaluated by comparing the administration of MQ as a single intake with its administration as split dose in two days. In total 4716 pregnant women will be enrolled at the antenatal clinic (ANC) and will be followed until the infant is one year old. Besides, in those countries where HIV prevalence in pregnant women is > 10%, MQ-IPTp will be compared to Placebo-IPTp in HIV infected pregnant women receiving cotrimoxazole (CTX) prophylaxis. This trial will be double blinded and will be carried out in Kenya, Tanzania and Mozambique. It will involve 1070 pregnant women that will be followed until the infant is 2 months old.

HIV-negative pregnant women receiving 2 doses of IPTp (500mg of sulfadoxine and 25 mg of pyrimethamine) in the context of long lasting Insecticide Treated Nets (LLITNs)

HIV-negative pregnant women receiving 2 full doses of IPTp (15 mg/Kg) in the context of long lasting Insecticide Treated Nets (LLITNs)

HIV-negative pregnant women receiving 2 doses of MQ as IPTp split dose over 2 days (15mg/kg) in the context of long lasting Insecticide Treated Nets (LLITNs

HIV-positive pregnant women receiving 3 doses of IPTp (placebo) in the context of long lasting Insecticide Treated Nets (LLITNs)

HIV-positive pregnant women receiving 3 doses of IPTp (15 mg/Kg) in the context of long lasting Insecticide Treated Nets (LLITNs)

SP oral administration (500mg sulphadoxine and 25mg pyrimethamine) as IPTp at the 1st and 2nd Antenatal Clinic visit

Trial 1: Prevalence of placental P. falciparum infection. Prevalence of moderate maternal anaemia at delivery.

Trial 2: Prevalence of placental P. falciparum infection. Prevalence of low birth weight babies (< 2500 g).

Inclusion Criteria: Trial 1: Permanent resident in the area Gestational age at the first antenatal visit ≤ 28 weeks Signed informed consent Agreement to deliver in the study site's maternity(ies) wards Trial 2: Permanent resident in the area. Gestational age at the first antenatal visit ≤ 28 weeks HIV seropositive (after voluntary counseling and testing) Indication to receive CTX prophylaxis (according to the national guidelines) Signed informed consent Agreement to deliver in the study site's maternity(ies) wards. Exclusion Criteria: Trial 1: Residence outside the study area or planning to move out in the following 18 months from enrollment Gestational age at the first antenatal visit > 28 weeks of pregnancy Known history of allergy to sulfa drugs or mefloquine Known history of severe renal, hepatic, psychiatric or neurological disease MQ or halofantrine treatment in the preceding 4 weeks HIV infection Participating in other studies Trial 2: Residence outside the study area or planning to move out in the following 10 months from enrollment Gestational age at the first antenatal visit > 28 weeks of pregnancy Known history of allergy to CTX or MQ Known history of severe renal, hepatic, psychiatric or neurological disease MQ or halofantrine treatment in the preceding 4 weeks

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