East African HIV programmes must wake up to visceral leishmaniasis

ADDIS ABABA/NAIROBI, 8 December 2011 – Improving the capacities of HIV programmes to prevent, diagnose and treat visceral leishmaniasis (VL) should be a priority in East Africa, international medical humanitarian organisation Médecins Sans Frontières (MSF) said today at the ICASA AIDS Conference currently being held in the Ethiopian capital Addis Ababa.

Visceral leishmaniasis, also known as ‘kala azar’, is a neglected parasitic disease spread through the bite of a sandfly. Visceral leishmaniasis is endemic in 76 countries worldwide. In East Africa, regions in Ethiopia, Kenya, Sudan and South Sudan are particularly affected. The disease is fatal without treatment.

 “People living with HIV are particularly vulnerable, so it’s critical that HIV programmes kick start a response to this neglected disease,” said Dr. Rachel ter Horst, medical advocacy advisor with MSF, who presented MSF field experience and research on the management of HIV/VL co-infection at ICASA. “In countries like Ethiopia where HIV and visceral leishmaniasis interact and co-infection is a problem, HIV programmes are essentially faced with the same paradigm as with tuberculosis. HIV programmes have learnt to think TB – they also need to learn to think visceral leishmaniasis.”

North-western Ethiopia has the highest burden of HIV/VL co-infection, as around one in three patients with visceral leishmaniasis is also HIV-positive.

Visceral leishmaniasis interacts with HIV in many ways. People living with HIV are at much higher risk to develop this disease. Visceral leishmaniasis accelerates progression to AIDS. Relapses are almost inevitable in people living with HIV and HIV-positive patients respond less well to anti-leishmanial treatment with each subsequent relapse. But successful treatment of the first episode of visceral leishmaniasis and early initiation of antiretroviral therapy may delay and reduce relapses.

“As a first step, HIV programmes in areas that are endemic for visceral leishmaniasis should actively screen people living with HIV for this life-threatening disease,” said Dr. Ter Horst. “Co-infected patients should then be given antiretrovirals as soon as possible after starting anti-leishmanial therapy.”

New data presented at ICASA by MSF suggests that the use of high-dose combination treatment regimens for co-infected patients can improve survival in the longer-term: early results suggest that treatment with liposomal amphotericin B at higher doses, combined with miltefosine, may have higher safety and efficacy than other options.

“Until now, treating people living with HIV who also suffer from visceral leishmaniasis has led to pretty bleak outcomes,” said Dr. Koert Ritmeijer, MSF health advisor. “Existing treatments were failing – some like SSG are too toxic and lead to high mortality in co-infected patients, others like liposomal amphotericin B are safe but aren’t effective enough.  We’re now seeing high-dose combination therapies have led to better initial cure rates, including in patients who had been cured of VL but have since suffered a relapse.”

Two clinical trials co-sponsored by MSF, the Drugs for Neglected Diseases initiative (DNDi), and the Institute of Tropical Medicine in Antwerp (ITM), and in collaboration with Gondar University in Ethiopia, will be implemented in 2012, both to confirm these promising results and to investigate the benefits of preventive therapy to reduce the occurrence of relapses.

“With the prospect of better treatment options, if the studies confirm these results, we hope that improved treatment guidelines will be implemented throughout the region in the near future,” said Dr. Ritmeijer.