title: A screen-and-treat strategy targeting visceral leishmaniasis in HIV-infected individuals in endemic East African countries: the way forward?
abstract: In the wake of the HIV epidemic, visceral leishmaniasis (VL), a disseminated protozoan infection caused by the Leishmania donovani complex, has been re-emerging, particularly in North Ethiopia where up to 40% of patients with VL are co-infected with HIV. Management of VL in HIV co-infection is complicated by increased drug toxicity, and high treatment failure and relapse rates with all currently available drugs, despite initiation of antiretroviral treatment. Tackling L. donovani infection before disease onset would thus be a logical approach. A screen-and-treat approach targeting latent or the early stage of infection has successfully been implemented in other HIV-associated opportunistic infections. While conceptually attractive in the context of VL-HIV, the basic understanding and evidence underpinning such an approach is currently lacking. Prospective cohort studies will have to be conducted to quantify the risk of VL in different risk groups and across CD4 cell count levels. This will allow developing clinical prognostic tools, integrating clinical, HIV and Leishmania infection markers. Interventional studies will be needed to evaluate prophylactic or pre-emptive treatment strategies for those at risk, ideally relying on an oral (combination) regimen. Issues like tolerability, emergence of resistance and drug interactions will require due attention. The need for maintenance therapy will have to be assessed. Based on the risk-benefit data, VL risk cut-offs will have to be identified to target treatment to those most likely to benefit. Such a strategy should be complemented with early initiation of antiretroviral treatment and other strategies to prevent HIV and Leishmania infection.
authors.affiliation: Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium.
authors.forename: Johan
authors.initials: J
authors.lastname: van Griensven
authors.affiliation: Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium; Department of Internal Medicine, University of Gondar, Gondar, Ethiopia.
authors.forename: Ermias
authors.initials: E
authors.lastname: Diro
authors.affiliation: Tropical Medicine. Infectious Diseases Department, Ramón y Cajal Hospital, Madrid, Spain.
authors.forename: Rogelio
authors.initials: R
authors.lastname: Lopez-Velez
authors.affiliation: Public Health Department, Médecins Sans Frontières, Amsterdam, The Netherlands.
authors.forename: Koert
authors.initials: K
authors.lastname: Ritmeijer
authors.affiliation: Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.
authors.forename: Marleen
authors.initials: M
authors.lastname: Boelaert
authors.affiliation: Rotterdam Centre for Tropical Medicine, Rotterdam, The Netherlands.
authors.forename: Ed E
authors.initials: EE
authors.lastname: Zijlstra
authors.affiliation: School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia.
authors.forename: Asrat
authors.initials: A
authors.lastname: Hailu
authors.affiliation: Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium.
authors.forename: Lutgarde
authors.initials: L
authors.lastname: Lynen
mesh_terms: D000351:Africa, Eastern / Q000453:epidemiology; D018791:CD4 Lymphocyte Count; D060085:Coinfection / Q000453:epidemiology; D015658:HIV Infections / Q000150:complications*; D006801:Humans; D007898:Leishmaniasis, Visceral / Q000175:diagnosis / Q000453:epidemiology / Q000517:prevention & control* / Q000628:therapy; D016133:Polymerase Chain Reaction; D011446:Prospective Studies
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