The World Health Organization publishes new guidelines with treatment recommendations specific to each region

The World Health Organization (WHO) has published new treatment recommendations for visceral leishmaniasis in patients infected with the human immunodeficiency virus (HIV). The guidelines target visceral leishmaniasis in East Africa and Southeast Asia.

Visceral leishmaniasis, or kala azar, has a different cause leishmaniasis Species in distinct geographic regions.1 In East Africa (Ethiopia, South Sudan, Sudan) and Southeast Asia (Bangladesh, India, Nepal), it is caused by L. donovani He has a human being2 Cycle with a human tank.

“There is a need for optimal area-specific treatment regimens due to the varying virulence and drug susceptibility of parasites.Dr Saurabh Jain, Medical Officer, Global Leishmaniasis Programme, WHO Department of Control of Neglected Tropical Diseases said. “Also, very few studies were conducted in the past in leishmaniasis-endemic regions other than Europe, which made it difficult to make appropriate recommendations for specific geographic locations.”

The new recommendations are based on the results of studies conducted in India3 By MSF and its partners, and in Ethiopia4 By Neglected Diseases Drugs Initiative and partners. It is expected to increase access to treatment and improve treatment outcomes, thus benefiting national control programs for neglected tropical diseases, HIV, tuberculosis, and vector-borne diseases. Up to 5-7% of visceral leishmaniasis patients in India have been detected with HIV – the highest in South Asia; A large proportion also suffer from another fatal comorbidity: tuberculosis.5

New evidence and better treatment

The new guide updates 2010 recommendations that were based on limited evidence primarily extrapolated from experiences in countries around the Mediterranean Basin where zoonoses are common. L. infantum It is the main causative type. Recommended treatment consists of daily injections of amphotericin B (AmBisome) over a period of up to 38 days.

However, evidence from studies in Ethiopia and India shows that a new regimen that combines liposomal amphotericin B with oral miltefosine performs better. In India, the treatment outcome was better, with a relapse-free survival of 96% versus 88% for standard treatment.

We welcome the new recommendations as well as key indicators for monitoring the outcome of patients with co-infection as this will accelerate efforts towards eliminating kala azar as a public health problem.” said Rodrico H. Ofrin, WHO Representative in India.

In Ethiopia, the rate of co-infection with visceral leishmaniasis and HIV has increased by 20-30% since the early 1980s, with the highest rate of co-infection in the world. Although the rate is somewhat low, co-infection remains a major public health challenge. The new combination regimen showed an increased efficacy (88%) compared to the current standard treatment (55%).6

We have a long experience in the use of different drugs and regimens to treat VLHIV patients, who were less efficient and had high toxicity, relapses and death”, said Mr. Tesfahun Bishaw Mengistie, Leishmaniasis Coordinator, 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-associated infection

leishmaniasis HIV co-infection has challenged the control and eradication of visceral leishmaniasis, as HIV-infected persons are particularly susceptible to this disease. leishmaniasis and HIV are mutually reinforcing, causing major clinical and public health problems.

Both conditions suppress the immune system, resulting in more severe morbidity with limited treatment options and higher rates of relapse, exposure to drugs with increased toxicity and higher mortality rates.

Co-infection was first reported in the mid-1980s in southern Europe, and has now been documented in as many as 45 countries. High rates have been reported from Brazil, Ethiopia and Bihar in India.

Patients with co-infections are vulnerable not only to other conditions such as tuberculosis and malignant meningitis but also to varying degrees of stigma and human rights issues.

The new WHO guideline offers hope for patients with co-infections and fills an important gap in allowing countries with both diseases to adapt the guideline to treat complex clinical cases.

Leishmaniasis – disease

Leishmaniasis is caused by more than 20 parasites leishmaniasis Ocean. More than 90 species of sandfly are known to be transmitted leishmaniasis parasites; There are 3 main forms of the disease:

visceral leishmaniasisFatal if left untreated, it is characterized by irregular episodes of fever, weight loss, enlarged spleen and liver, and anemia.

cutaneous leishmaniasis: The most common form that causes skin lesions, especially ulcers, on exposed parts of the body, leaving lifelong scars and a serious disability or stain.

Mucocutaneous leishmaniasis: leads to partial or complete destruction of the mucous membranes of the nose, mouth and throat.

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  1. 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 World Health Organization. Visceral leishmaniasis remains a major parasitic disease with potential for outbreaks and death. In 2020, more than 90% of new cases were reported to WHO from 10 countries: Brazil, China, Ethiopia, Eritrea, India, Kenya, Somalia, South Sudan, Sudan and Yemen.

  2. An infection or disease that is transmitted from human to animal under natural conditions.

  3. AmBisome monotherapy and AmBisome-Miltefosine combination therapy for the treatment of visceral leishmaniasis in HIV-infected patients in India: a randomized, open-label, parallel-arm, phase 3 trial.
    https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciac127/6527047

  4. A randomized trial of AmBisome, AmBisome, and Miltefosine monotherapy for the treatment of visceral leishmaniasis in HIV-infected patients in Ethiopia
    https://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0006988

  5. Infection with visceral leishmaniasis and pulmonary tuberculosis is a public health problem in many countries. Leishmaniasis infection can alter the protective immune response to the BCG vaccine against tuberculosis https://parasitesandvectors.biomedcentral.com/articles/10.1186/1756-3305-6-79accessed June 1, 2022.

  6. The current standard treatment for co-infection with HIV/visceral leishmaniasis includes a single injection of lipid amphotericin B (LAmB). The new treatment course is a combination of oral miltefosine and LAmB.

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