Clinical management of Visceral Leishmaniasis in HIV Patients in Ethiopia
26 mei 2015
UAntwerp, Campus Drie Eiken, Building Q, Promotiezaal - Universiteitplein 1 - 2610 Wilrijk
Organisatie / co-organisatie:
Faculty of Medicine and Health Sciences
Ermias Diro Ejara
Prof L. Lynen & Prof A. Hailu
PhD defence Ermias Diro Ejara - Faculty of Medicine and Health Sciences
Visceral leishmaniasis (VL), also called kala-azar, has emerged as an important opportunistic infection in the era of HIV. HIV accelerates VL disease progression and atypical manifestations are frequent. The immune deficiency status of the patient makes cure difficult for all available anti-leishmania drugs, and relapse is common. The two diseases reinforce each other and lead to profound immune deficiency and failure of treatment in both.
This research was conducted in northwest Ethiopia where the co-infection rate reaches 10-20%. It describes the challenges the clinical management and options of improving it. Cases with oral and rectal lesions, abdominal lymph node involvement and disseminated skin manifestations of VL in patients with HIV infection were described to alert clinicians on atypical manifestations of VL. The one month sodium stibogluconate treatment outcome of VL in HIV co-infected patients showed cure rate of only 43%, and with 25% of the cases interrupting the treatment due to toxicity. Treatment prolongation improved the success rate to 75%. These findings indicate the need for safe and effective alternative drugs and for the establishment of a surveillance system for monitoring resistance against anti-leishmania drugs.
With the use of pentamidine as a secondary prophylaxis in a clinical trial involving 74 HIV co-infected VL patients the probability of one year relapse free survival was 71%. Previous studies showed relapse rate of 50%-100% without prophylaxis. Low CD4+ cell count was identified as an important risk factor for relapse. Thus, it is important to detect VL in HIV patients before profound immune deficiency supervenes. While antiretroviral therapy (ART) improves the immune status of HIV patients, optimizing ART regimens for VL and HIV co-infected patients might be important.
In vitro studies showed the anti-leishmania effect of HIV protease inhibitor drugs. The enhanced CD4 recovery with protease inhibitor containing ART regimens might also have clinical benefit on the treatment outcome of VL co-infection. Further research is needed to explore the role of protease inhibitors in HIV/VL co-infection. As the management of these two diseases continues to be challenging, the prevention and control need to be give due attention.