Clinical aspects of visceral leishmaniasis in HIV infection.

HIV infection profoundly impairs the immune mechanisms needed to control and clear Leishmania infection, and outcomes in patients with HIV-associated visceral leishmaniasis are poor. This review summarizes recent work describing the epidemiology, presentation and outcomes of HIV-associated visceral leishmaniasis and discusses advances in diagnosis and management. Studies have shown that serological tests can effectively diagnose HIV-associated visceral leishmaniasis, with a sensitivity of 98% if direct agglutination test and rK39 assays are used in combination. Few data exist to guide treatment recommendations. Observational data show high rates of toxicity and treatment failure with pentavalent antimonials, and their use is no longer recommended. Liposomal amphotericin B (L-AmB) is better tolerated, but outcomes are suboptimal, with mortality rates of 7-12%, and parasitological failure rates of up to 32%. Initial reports suggest that L-AmB and miltefosine in combination may be effective in HIV-associated visceral leishmaniasis; however, clinical trial data are lacking. Secondary prophylaxis reduces the rate of relapse, but optimal regimens have not been defined, and optimal timing of antiretroviral therapy initiation in patients with visceral leishmaniasis is unknown. Recent studies have demonstrated the inadequacy of current treatments for HIV-associated visceral leishmaniasis. Clinical trials are needed to improve early diagnosis, develop combination therapies and define effective secondary prophylaxis regimens.