Treatment training manual

5.15 Malaria

Type of illness

Malaria is a parasite infection of red blood cells.

Malaria is transmitted to humans by a bite from a female Anopheles mosquito. There can be a delay of one week to one year between getting infected and having symptoms.

Most people who grow up in malarial areas have some immunity to the illness. Malaria is usually an acute (short-term) illness, but for some people it becomes a chronic (life-long) problem.

The risk of malaria is related to where you live and whether this is in a high-risk country or region, and by season. Malaria is the one of the leading causes of death in children under 5 who live in areas affected by malaria.

In people with HIV:

  • Acute malaria infection is not an OI.
  • Chronic malaria is considered a coinfection.

Main symptoms

  • Shaking chills.
  • High fever and sweating.
  • Dizziness, nausea, vomiting, abdominal cramps.
  • Headache and back ache.
  • Tiredness.
  • Sometimes jaundice (yellowing of skin and eyes).

Malaria attacks happen over 4 to 6 hours, and occur every 2 or 3 days.

If malaria affects the brain, it can be fatal within 24 hours.

Malaria can cause anaemia.

Malaria and HIV

HIV increases the risk of malaria infection, and the malaria is more severe. HIV makes malaria worse.

  • There is a higher density of parasites.
  • The symptoms last for longer.
  • A low CD4 count and high viral load increases this risk.
  • There is an increased risk of reinfection (with a new infection) within 28 days of treatment.
  • Malaria increases HIV viral load which may affect long term health.
  • It is not like a typical OI because childhood immunity is often retained in adults.

Malaria, pregnancy and anaemia

Pregnant women are three times more likely to catch malaria compared to non-pregnant women.

The increase in viral load from malaria coinfection increases the risk of HIV transmission in HIV positive pregnant women, and causes lower birth weight in the baby.

Haemoglobin levels are lower in coinfected pregnant women and the risk of anaemia is higher. This has to be taken very seriously and managed appropriately.

This usually means that the risks from not treating malaria are greater than the difficulties from treatment (ie drug interactions).


Malaria is diagnosed by physical examination and blood tests.

Information about travel history and symptoms are important.


Malaria can be treated with inexpensive drugs and can usually be cured.

The choice of drugs depends on whether the malaria in your region has developed resistance to treatment.

Malaria is usually treated with a combination of drugs. Several antimalarial drugs and combinations are available.

  • Chloroquine-based treatment used to be the most widely used first-line therapy. It is also the most effective therapy, but is now also associated with most drug resistance.
  • Artemisinin + lumefantrine are now more widely used in chloroquine-resistant regions.

Please check the Liverpool University online checker for details pf interactions between some malaria drugs and some HIV drugs. Malaria drugs are listed under antiprotazoals.

  • There are no interactions with integrase inhibitors or with NRTIs
  • Halofantine – don’t give with PIs.
  • Artemether – don’t give with PIs, levels reduced by some NNRTIs.
  • Lumefantine – don’t give with PIs, levels reduced by some NNRTIs.
  • Quinine – unclear if there are PI or NNRTI interactions.


One of the most effective ways to stop malaria is to use insecticide-treated bed nets.

These nets cost less than $5 and can reduce all-cause child mortality by 25%. This is part of a major international campaign to reduce infant mortality from malaria.

Oral prophylaxis is with co-trimoxazole (Septrin), which also protects against PCP and toxoplasmosis.


Research on malaria is looking at the following areas:

  • Resistance to treatment is a serious problem – new drugs are being looked at.
  • Effect of malaria in HIV positive children.
  • Does better malaria treatment improve management of HIV?
  • Implications of co-trimoxazole treatment for protection and the risk of resistance.
  • Drug interactions between malaria treatment and ARVs.
  • Early studies using bNAbs and vaccines against malaria.

Links and further reading

Last updated: 1 January 2023.