title: Concordant HIV infection and visceral leishmaniasis in Ethiopia: the influence of antiretroviral treatment and other factors on outcome.
abstract: BACKGROUND
  Coinfection with human immunodeficiency virus (HIV) and Leishmania donovani visceral leishmaniasis (VL) in Africa is an emerging, poorly understood disease.
  
  
  METHODS
  We evaluated 356 consecutive patients coinfected with HIV and VL treated in Humera, northwest Ethiopia, from February 2003 to October 2006, for risk factors for VL relapse and death and the effect of antiretroviral therapy (ART).
  
  
  RESULTS
  During 2928 patient-months of follow-up, 256 VL episodes and 39 deaths occurred. Among 195 patients receiving ART, 31.3% had > or = 1 VL episode, and 14.4% died. Among 161 patients who did not receive ART, 26.1% had > or = 1 VL episodes, and 6.8% died. A total of 54 patients who received ART and 58 patients who did not receive ART had > or = 1 VL relapse. VL relapse among patients receiving ART was associated with a baseline CD4 cell count < 100 cells/microL (hazard ratio [HR], 2.50; 95% confidence interval [CI], 1.21-5.15) and > or = 2 previous VL episodes (HR, 3.74; 95% CI, 1.40-10.02). Failure to clear parasites after VL treatment was usually followed by symptomatic VL relapse. Patients who relapsed showed poor CD4 cell count recovery while receiving ART. ART was partially protective against VL relapse (HR, 0.46; 95% CI, 0.26-0.82). However, 28% of first VL relapses while receiving ART occurred despite a CD4 cell count > 200 cells/microL; in 5% of VL relapses, the CD4 cell count had been > 200 cells/microL for > 6 months. Factors associated with all-cause mortality among patients receiving ART were baseline CD4 cell count < 100 cells/microL (HR, 3.20; 95% CI, 1.30-7.87) and VL episodes during follow-up (HR for 1 episode, 4.97 [95% CI, 2.09-11.86]; HR for > 2 episodes, 3.22 [95% CI, 1.01-10.23]).
  
  
  CONCLUSIONS
  Concordant HIV infection and VL is a major, acquired immunodeficiency syndrome-defining illness with high relapse and mortality rates; ART reduces relapses; and secondary antileishmanial prophylaxis may benefit patients at risk of relapse.
authors.affiliation: Médecins Sans Frontières, Amsterdam, The Netherlands.
authors.forename: Rachel
authors.initials: R
authors.lastname: ter Horst
authors.forename: Simon M
authors.initials: SM
authors.lastname: Collin
authors.forename: Koert
authors.initials: K
authors.lastname: Ritmeijer
authors.forename: Adey
authors.initials: A
authors.lastname: Bogale
authors.forename: Robert N
authors.initials: RN
authors.lastname: Davidson
mesh_terms: D017088:AIDS-Related Opportunistic Infections / Q000453:epidemiology* / Q000401:mortality / Q000517:prevention & control; D000818:Animals; D019380:Anti-HIV Agents / Q000627:therapeutic use; D000981:Antiprotozoal Agents / Q000627:therapeutic use; D023241:Antiretroviral Therapy, Highly Active; D015704:CD4 Antigens / Q000032:analysis; D018791:CD4 Lymphocyte Count; D005002:Ethiopia / Q000453:epidemiology; D015658:HIV Infections / Q000188:drug therapy / Q000453:epidemiology*; D006801:Humans; D007898:Leishmaniasis, Visceral / Q000453:epidemiology* / Q000517:prevention & control; D016896:Treatment Outcome
chemical_list: D019380:Anti-HIV Agents; D000981:Antiprotozoal Agents; D015704:CD4 Antigens