The World Health Organization (WHO) has published new treatment recommendations for visceral leishmaniasis in patients who are co-infected with the human immunodeficiency virus (HIV). The guide is aimed at visceral leishmaniasis in East Africa and Southeast Asia.
Visceral leishmaniasis, or kala azar, is caused by different species of Leishmania in different geographical areas and has an anthroponotic cycle2 with a human reservoir.
“Optimal treatment regimens specific to the region are needed because the virulence of the parasites and the susceptibility to the drugs are different,” said Dr. Saurabh Jain, medical officer of the Global Leishmaniasis Program, Department of Tropical Disease Control. ‘WHO. “In addition, very few studies have been conducted in the endemic regions of leishmaniasis other than Europe in the past, and this has made it difficult to provide appropriate recommendations for specific geographical environments.”
The new recommendations are based on the results of studies conducted in India3 by Médecins Sans Frontières and its partners, and in Ethiopia4 by the Drugs for Neglected Diseases initiative and partners. They are expected to increase access to treatment and improve treatment outcomes, and therefore benefit national programs to control neglected tropical diseases, HIV, tuberculosis, and vector-borne diseases. Up to 5-7% of patients with visceral leishmaniasis in India are detected with HIV infection, the highest in South Asia; a significant proportion also suffer from another fatal comorbidity: tuberculosis.5
New tests and better treatment
The new guide updates the 2010 recommendations which were based on limited evidence extrapolated mainly from experience in Mediterranean basin countries where the zoonotic L. infantum is the main causative species. The recommended treatment consisted of daily injections of liposomal amphotericin B (AmBisome) for a period of up to 38 days.
However, evidence from studies in Ethiopia and India shows that the new regimen combining liposomal amphotericin B with oral miltefosine works best. In India, the outcome of treatment was superior, with a relapse-free survival of 96% compared to 88% of standard treatment.
“We welcome new recommendations as well as key indicators to monitor the outcomes of co-infected patients, as this has the potential to accelerate efforts to eliminate kala azar as a public health problem,” said Roderico H .Offrin, WHO Representative in India.
In Ethiopia, coinfection between visceral leishmaniasis and HIV has increased by 20 to 30 percent since the early 1980s, with the highest rate of coinfection in the world. Although the rate has decreased slightly, coinfection remains a major public health challenge. The new combination regimen was more effective (88%) compared to the current standard treatment (55%).
“We have a long history of using different medications and regimens to treat patients with VL-HIV, who were less efficient and had high toxicity, relapse, and mortality,” Mr. Tesfahun Bishaw Mengistie, Head of Leishmaniasis, Directorate of Disease Prevention and Control. Federal Ministry of Health, Addis Ababa, Ethiopia. “We welcome the new recommendations as they ensure better management of this complex condition.”
Visceral leishmaniasis and HIV coinfection
Co-infections with leishmaniasis and HIV have challenged the control and elimination of visceral leishmaniasis, as people infected with HIV are especially vulnerable to the disease. Leishmania and HIV are mutually reinforcing, posing important clinical and public health issues.
Both conditions suppress the immune system, resulting in more severe morbidity with limited treatment options and higher relapse rates, exposure to drugs with increased toxicity, and higher mortality rates.
It was first reported in the mid-1980s in southern Europe, now coinfection is documented in up to 45 countries. High rates have been reported in Brazil, Ethiopia and the state of Bihar in India.
Coinfected patients are vulnerable not only to other comorbid conditions such as tuberculosis and cryptococcal meningitis, but also to varying degrees of stigma and human rights issues.
The new WHO guideline offers hope to co-infected patients and fills a significant gap to allow countries where both diseases are common to adapt the guideline for the treatment of complex clinical cases.
Leishmaniasis – the disease
Leishmaniasis is caused by a protozoan parasite of more than 20 species of Leishmania. More than 90 species of flebrot are known to transmit Leishmania parasites. There are 3 main forms of the disease:
Visceral leishmaniasis: fatal if left untreated, characterized by irregular bouts of fever, weight loss, enlargement of the spleen and liver, and anemia.
Cutaneous Leishmaniasis: The most common form that causes skin lesions, mostly ulcers, on exposed parts of the body, leaving scars for life and severe disability or stigma.
Mucocutaneous leishmaniasis: leads to the partial or total destruction of the mucous membranes of the nose, mouth and throat.
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Most cases of visceral leishmaniasis occur in Brazil, East Africa, and India, with an estimated 50,000-90,000 new cases worldwide annually; only 25-45% of cases are reported to the WHO. Visceral leishmaniasis remains one of the major parasitic diseases with potential for outbreak and mortality. By 2020, more than 90% of new cases were reported to the WHO in 10 countries: Brazil, China, Ethiopia, Eritrea, India, Kenya, Somalia, South Sudan, Sudan and Yemen.
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Infection or disease that is transmitted from humans to animals under natural conditions.
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AmBisome-Miltefosine AmBisome Monotherapy and Combination for the Treatment of Visceral Leishmaniasis in Patients Co-Infected with Human Immunodeficiency Virus (HIV) in India: A Randomized Phase 3 Trial, Parallel and Open Arm
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A randomized trial of AmBisome monotherapy and a combination of AmBisome and miltefosine to treat visceral leishmaniasis in HIV-infected patients in Ethiopiahttps: //journals.plos.org/plosntds/article? Id = 10.1371 / journal.pntd.0006988
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Co-infection with visceral leishmaniasis and pulmonary tuberculosis is a public health problem in many countries. Leishmaniasis infection may alter the protective immune response to the BCG vaccine against tuberculosis consulted on June 1, 2022.
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Current standard treatment for HIV / visceral leishmaniasis coinfection includes individual injections of liposomal amphotericin B (LAmB). The new course of treatment is a combination of miltefosine and LAmB oral treatment.