Treatment of Visceral Leishmaniasis in HIV Co-Infected Patients in East Africa and South-East Asia
WHO recommendations on treatment of visceral leishmaniasis in HIV co-infected patients
Visceral Leishmaniasis patients with HIV coinfection in East Africa
Visceral Leishmaniasis patients with HIV coinfection in South-East Asia
Considerations
- Determine the HIV status of patients diagnosed with VL. Routinely screen for tuberculosis at visceral leishmaniasis diagnosis and follow-up.
- In patients who do not show a good clinical response, after ruling out other diagnoses, consider providing extended therapy (one repetition of the same therapy, based on evidence from trials in Ethiopia).
- When miltefosine is not available, consider using monotherapy with L-AMB (up to a total of 40 mg/kg) as per the L-AMB regimen.
- Provide comprehensive clinical management, including adequate HIV treatment and nutritional support.
- Ensure access to contraception and pregnancy testing for women of child-bearing potential before administering miltefosine.
WHO recommendation for secondary prophylaxis after recovery from a first episode of visceral leishmaniasis in HIV co-infected patients
Remarks
- Secondary prophylaxis is recommended in particular for patients at high risk of relapse (e.g., patients not on ART, with a low CD4 cell count (< 200 cells/mm3), multiple previous VL episodes, failure to achieve clinical or parasitological cure during the first episode of VL, no increase in CD4 cell count at follow-up). Patients should be evaluated case by case.
- As the recommendation for secondary prophylaxis applies specifically to HIV-positive individuals, it is important to determine the HIV status of patients diagnosed with VL.
- In East Africa: pentamidine isethionate at 4 mg/kg per day [300 mg for an adult]) every 3–4 weeks. In South-East Asia: amphotericin B deoxycholate at 1 mg/kg every 3–4 weeks or Liposomal amphotericin B (L-AMB) at 3–5 mg/kg per day every 3–4 weeks
- Prophylaxis can be stopped if the CD4 cell count is maintained at or > 350 cells/mm3 or the HIV viral load is undetectable for at least 6 months and there is no clinical evidence of VL relapse.
- When choosing a drug for secondary prophylaxis, consider: using drugs that were not used to treat the primary VL episode, the benefits and safety profiles of the proposed drug, potential collateral benefits in terms of prevention of other infections, and potential drug resistance.
Considerations
- Improve access to HIV testing for all patients with VL.
- Ensure uninterrupted, free access to quality-assured medicines.
- Ensure appropriate access to health-care services at the lowest possible direct and indirect cost.
- Extend the supplier base of antileishmanial diagnostic tests and medicines.
- Strengthen the relevant health infrastructure and human resource capacity.
- Improve coordination among HIV, VL and related programmes, such as for pharmacovigilance, TB and vector control.
Recommendation Grading
Overview
Title
Treatment of Visceral Leishmaniasis in HIV Co-Infected Patients in East Africa and South-East Asia
Authoring Organization
World Health Organization
Publication Month/Year
June 6, 2022
Last Updated Month/Year
April 1, 2024
Document Type
Guideline
Country of Publication
US
Document Objectives
This document describes the management of VL caused by L. donovani in HIV co-infected patients in East Africa and South-East Asia. The recommendations are also applicable to other areas endemic for L. donovani. The guidelines update the recommendations in the report of a meeting of the WHO Expert Committee on the Control of Leishmaniases (WHO Technical Report Series 949) in 2010. Previously, treatment for VL in HIV co-infected patients was based on limited evidence, extrapolated mainly from experience in countries around the Mediterranean Basin, with L. infantum as the main species. As parasite virulence and drug susceptibility differ, the optimal treatment regimens for VL in HIV co-infected patients in areas in which VL is caused by L. donovani (East Africa and South-East Asia) were not known. The few studies conducted in leishmaniasis-endemic regions other than Europe made it difficult to provide clear, region-specific recommendations. These guidelines, based on recent evidence from clinical trials in Ethiopia and India, fill this gap.
Inclusion Criteria
Male, Female, Adult, Older adult
Health Care Settings
Ambulatory, Hospital, Outpatient
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Treatment, Management
Diseases/Conditions (MeSH)
D006678 - HIV, D007896 - Leishmaniasis, D007898 - Leishmaniasis, Visceral
Keywords
leishmaniasis, HIV infections, HIV/AIDS, HIV, HIV-1, visceral leishmaniasis, co-infections
Source Citation
WHO guideline for the treatment of visceral leishmaniasis in HIV co-infected patients in East Africa and South-East Asia [Internet]. Geneva: World Health Organization; 2022. PMID: 35763584.