Visceral leishmaniasis/HIV co-infection in East Africa

By: Julien Potet, Neglected Tropical Diseases Policy Advisor at Médecins Sans Frontières’ Campaign for Access to Essential Medicines

Today is the last day of the 16th International Conference on AIDS and STIs in Africa (ICASA), in Addis Ababa, Ethiopia. Ethiopia is a hotspot for cases of co-infection between HIV and visceral leishmaniasis: around one-third of patients with visceral leishmaniasis in North-West Ethiopia are also HIV-positive. With ICASA this year being held in the heart of where most cases of HIV and visceral leishmaniasis occur, it presents a unique opportunity to highlight both the danger of visceral leishmaniasis among the HIV community, and the measures to be taken to address this deadly co-infection.

Visceral leishmaniasis endemic areas in East Africa.

Visceral leishmaniasis, also known as kala azar, is a vector-borne neglected parasitic disease that is fatal if left untreated. It affects between 250,000 and 300,000 people each year worldwide. In East Africa, cases of visceral leishmaniasis are driven by many factors, including the weakness of health systems, the displacement of non-immune populations and the HIV pandemic.

Visceral leishmaniasis can not be fully cured in people living with HIV in East Africa. Relapses are almost inevitable and people living with HIV become more drug-unresponsive 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. Medecins Sans Frontieres (MSF) has found that customised treatment for visceral leishmaniasis in HIV-positive people can improve their survival rates over time.

MSF will today present to the ICASA delegates its latest data showing that liposomal amphotericin B (marketed as AmBisome)/miltefosine is a promising combination treatment in HIV-positive kala azar patients in Africa. It is safe and has shown better outcomes than other treatments in the field in North-West Ethiopia. A clinical trial carried out by MSF, Drugs for Neglected Diseases initiative (DNDi) and Gondar University will start early next year to confirm these results. The trial will also evaluate the benefits of monthly injections of another drug, pentamidine, in possibly preventing relapses in HIV-positive people after they have been treated for visceral leishmaniasis.

With new and better treatment strategies being validated, it is time for East African countries where visceral leishmaniasis is endemic – mainly Sudan, South Sudan, Ethiopia and Kenya – to scale up their capacities for integrated diagnosis and treatment of HIV and visceral leishmaniasis. Last month, Kenya became the first African country to launch a five-year comprehensive plan on neglected tropical diseases, including visceral leishmaniasis. This is a great start, but an estimated US $70 million is needed to fully fund the plan. Donors should include interventions that scale up diagnosis and treatment of visceral leishmaniasis in HIV funding and allocation. The Global Fund to Fight AIDS, Tuberculosis and Malaria could play a prominent role here, but it currently faces a very serious funding crisis.

A patient with visceral leishmaniasis at Kahsay Abera Hospital in Humera, north-west Ethiopia. Photo credit: Sven Torfinn / HH

In practice, all people living with HIV in endemic areas should be examined for visceral leishmaniasis. People should be encouraged to sleep under insecticide-treated bed nets, even though they offer only limited protection from the sandfly that transmits leishmaniasis. An HIV test should be offered to all patients with visceral leishmaniasis as it determines the choice of treatment. Financial and technical assistance for HIV treatment centres in the region is essential for these centres to offer quality services in case management of visceral leishmaniasis.

Last but not least, access to these critical drugs needs to be enhanced; not all drugs for visceral leishmaniasis are registered in East African countries and the high prices of liposomal amphotericin B and miltefosine limit their use outside the field programmes that are implemented by international organisations such as MSF.

There is still a long way to go to ending the neglect and drastically improving HIV/visceral leishmaniasis co-infection case-management in Africa. But the future looks brighter than before. Support from HIV activists will be essential to advocate for the scale up of the best available treatment strategies and to stimulate research of safe treatments that could guarantee a permanent cure of visceral leishmaniasis in HIV-positive people over time.

 

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