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Treatment HIV-VL

There is no regimen that was found effective and promising for VL in HIV co-infected patients. For safety reasons, liposomal amphotericin B with or without miltifosine is preferred from the currently available drugs.

Recommended regimen:

-        Liposomal amphotericin B 5mg/kg per dose on days 1 to 5 and three weekly additions (total of 40mg/kg dose)

-        Liposomal amphotericin B 5mg/Kg per dose for six doses (total 30mg/Kg) on alternate days Plus Miltefosine 50mg PO BID (preliminary findings of a clinical trial in North Ethiopia showed better outcome with this regimen).

-        Combination and prolonged regimens are used on compassionate purposes for non-responding and relapsing patients. Treating physicians have to be careful about adverse drug effects.

Management of treatment failures:

Treatment outcome should  better be assessed parasitologically in HIV co-infected patients with test of cure (ToC) as the clinical evaluation alone will not be enough. With frequent relapses the typical manifestations diminish. There are no studies showing that demonstrated the best management options for treatment failures. However, these recommendations are based on expert opinions. Experiences showed that high parasitemia (>+4) at ToC or a reduction of parasite load only with 2+ or less, requires change of the initial drug used. That means, if a patient was treated with SSG first, then it should better be changed to AmBisome or the vice versa. If the ToC result still shows LD bodies, but less than +4 load or reduction by more than +2 from the pretreatment level, the treatment can be prolonged with the same regimen.

ART should be initiated as soon as patients are able to tolerate it or it should be continued for patients already on ART.

One has to be careful about drug-drug interaction and added toxicities.

Secondary prophylaxis: Most studies have shown the benefit of secondary prophyalxis for VL in HIV patients. Secondary prophyalxis should be started after the ToC become negative for LD bodies. Potentially, all antileishmania drugs can be used for this purpose. For anthroponotic transmission regions like East Africa, drugs that are used as first line and second line should be spared from use as secondary prophylaxis to minimize development of resistance. Monthly pentamidine infusion reduced relapse rate by more than 50% in a year. Secondary prophylaxis is not yet included in the Ethiopian national guidelines for VL in HIV patients.