Discussion
PWH, infections, HIV Recurrent parasitaemia, infection, parasitaemia
INFECTION, INFECTIONS, MALARIA
In this evaluation of AL therapeutic efficacy among PWH who are well controlled on ART, unadjusted overall treatment efficacy was lower than expected at 81% but after PCR-correction to exclude new infections, the adjusted treatment efficacy rate was 94%. This meets the WHO requirement for first-line anti-malarial agents to have at least 90% efficacy in therapeutic efficacy studies. This also confirms that the observed high rate of recurrent infection is not likely due to drug resistance. Although these findings confirm that resistance to AL is not clinically detectable in Malawi, high rates of new infections may be due to low lumefantrine levels that fail to protect against subsequent infections.Although the 94% efficacy is an acceptable rate, the results are lower than 99% treatment efficacy documented in a population of children around the same time in Malawi [The day seven 7 plasma lumefantrine levels were low in our population of adults living with HIV Recurrent parasitaemia was associated with lower lumefantrine levels. The low drug concentrations and recurrent parasitaemia were both more common in participants on efavirenz-based ART regimen than those taking other regimens, consistent with results of a previous meta-analysis [This study also supports the induction effect of efavirenz on lumefantrine metabolism through quantification of its primary metabolite, desbutyl-lumefantrine [A higher rate of treatment failure was observed among participants living in Zomba, a more rural area, compared to Blantyre, an urban centre. Malaria transmission intensity is higher in Zomba compared with Blantyre. Therefore, participants in Zomba were exposed to more infectious bites of Although the study did not identify a concerning level of anti-malarial resistance as evidenced by the 94% efficacy rate, low drug levels have the potential to impact the emergence and spread of resistance [