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Kala-Azar (Visceral Leishmaniasis) and HIV Coinfection in Bihar, India: Is This Combination Increasing?

2003; Lippincott Williams & Wilkins; Volume: 32; Issue: 5 Linguagem: Inglês

10.1097/00126334-200304150-00017

1944-7884

Chandreshwar Prasad Thakur, Shyam Narayan, Alok Ranjan,

Research on Leishmaniasis Studies

To the Editor: With two epidemics of kala-azar (visceral leishmaniasis [VL]) occurring in the recent past, one in 1977 with 100,000 cases and another in 1991 through 1992 with 250,000 cases, Bihar contributes 80% of total Indian cases, and Brazil, Sudan, India, Nepal, and Bangladesh contribute 90% of the total global burden of VL in the world (1). Bihar's migrant laborers go to southern Indian states that are economically advanced but are considered high-prevalence states for HIV; these migrant laborers then contract the disease there by indulging in high-risk sexual behavior. Thirty percent to 60% of kala-azar patients do not respond to sodium stibogluconate, the first-line drug in Bihar (2,3); it was suggested that this might be due to underlying HIV coinfection. This coinfection has been reported mostly from southern and western Europe, Spain, Italy, France, Portugal, and Brazil (4) and altogether from 33 countries. Except for a solitary case report (5), three studies done from the Bihar area did not find a single such coinfection (3,6,7). To resolve these contradictory observations, we undertook this study. Two hundred parasitologically confirmed kala-azar cases with 600 age- and sex-matched controls, who also came from the same area, were included in the study. Study subjects gave informed consent, and ethical clearance was obtained from the local ethics committee of Balaji Utthan Sansthan between January 2001 and March 2002. Spleen and liver size, body weight, total and differential white blood cell counts, serum aspartate transaminase, serum alanine transaminase, serum creatinine, hemoglobin, an electrocardiogram (ECG), and body weight measurements were taken, and a chest radiograph was taken in each kala-azar case. HIV tests among the kala-azar patients and their controls were done by enzyme immunoassay (Organic, Israel). All kala-azar patients were treated with amphotericin B given at a dose of 1 mg/kg body weight as a slow intravenous infusion for 2 hours daily for 20 days (8). Data taken from the National AIDS Control Society (NACO) of Bihar and India were used for comparison. The initial characteristics of kala-azar patients, HIV status of kala-azar patients and controls, and predisposing factors for HIV infection are given in Table 1. Three patients (1.5%) with kala-azar were identified, and 25 (4.1%) controls were positive for HIV. The difference between the two groups were not significant (p > .05, Yates corrected χ2 = 2.4 at 1 df). Two persons below the age of 22 years, 4 between 20 and 29 years of age, 16 between 30 and 44 years of age, and 6 who were at least 45 years of age were HIV infected. The proportion of HIV-infected persons in the age group from 30 to 44 years was significantly greater than in any other age group (p < .05, χ2 = 15.37). Twenty-two men and 6 women were found positive with a female/male ratio of 1:3.6. There was no significant difference between the two groups (p > .05; Yates corrected χ2 =0.55 at 1 df). Seventeen (61%) HIV-infected persons were from urban areas, and 11 (39%) were from rural areas; the difference between the two groups was highly significant (p < .05, χ2 = 42.43).TABLE 1: Initial clinical characteristics of kala-azar patients (n = 200), HIV status of kala-azar patients and controls (n = 600) and predisposing factors in HIV-infected personsSeventy-four percent of patients had a heterosexual mode of transmission. Eleven percent got the disease through a blood transfusion, 7% by transmission from husband to wife, 4% by homosexual transmission, and 4% by mother-to-child transmission. Seventy-one percent of HIV-positive subjects were infected by sex workers, 11% in the hospital, and 11% within family. Seventy-eight percent of the persons with HIV were illiterate, 18% matriculated, and 4% graduated (see Table 1). In India, there was a steady increase in the number of HIV cases from 1986 to 1994 and a sharp increase from 1994 onward. A decrease in the number of new infections was noted from 1998, however. The number of new infections was put at 0.11 million in 2001 compared with 0.16 million in 2000, whereas the total number of cases was 3.97 million in 2001, 3.86 million in 2000, and 4.1 million in 2002 (data taken from NACO). This study showed that 3 (1.5%) patients with kala-azar were found to be positive for HIV. When this coinfection was compared with 25 (4.1%) persons found positive for HIV among controls, there was no significant difference between the two groups. This indicated that the rise in the incidence of HIV and kala-azar coinfection was due to a general increase in the number of HIV cases in the society and not due to kala-azar as such. In Brazil, VL and leishmania coinfection also increased with the rise in AIDS cases (4). The maximum number of HIV-positive cases was seen in persons between 30 and 44 years of age. With 61% percent of patients coming from urban areas, 74% contracting the disease through the heterosexual route, 71% of transmission occurring at the residence of sex workers, and 78% of patients being illiterate (see Table 1), these represent the major thrust areas for formulating a prevention program. A free supply of condoms given to sex workers, proper sex and AIDS education, education of homosexuals through elderly homosexuals acting as a peer group, and a nevirapine prevention program for prevention of mother-to-child transmission succeeded in controlling the epidemics in Uganda, the United States, and Thailand (9–11). The same measures, if strictly applied, could also succeed in controlling the epidemics in India. It was concluded that the increase in incidence of kala-azar and HIV coinfection in Bihar had occurred due to an increase in the number of kala-azar and HIV/AIDS cases in the society. Measures adopted to control both diseases could be successful in controlling the rise of this coinfection, and this combination should be kept in mind when dealing with kala-azar cases. Acknowledgment: This study received financial support from the South East Asia Regional Office of the World Health Organization, New Delhi. *Chandreshwar Prasad Thakur †Shyam Narayan †Alok Ranjan