Visceral Leishmaniasis and HIV Coinfection in Bihar, India

To the Editor: Visceral leishmaniasis (VL) is caused by a protozoan parasite known as Leishmania donovani. Ninety percent of the global burden of VL is found in Brazil, Sudan, Bangladesh, and India. Nearly 80% of the cases in this region are reported from Bihar, India, alone (1). The disease is characterized by prolonged fever, anorexia, loss of weight, darkening of the skin, and hepatosplenomegaly with anemia. The disease is invariably fatal without treatment. Since the advent of the HIV/AIDS epidemic in 1981, currently 4.1 million people are living with HIV infection in India. A number of people from Bihar travel for work to various metropolitan cities in India, where HIV infection has become a serious problem among commercial sex workers (CSWs). While away from their families they engage in high-risk sexual activities with CSWs. Moreover, in the adjoining districts of Bihar with Nepal, cross-border transmission of infection is taking place. We report here coinfection of VL and HIV in Bihar. A total of 111 persons with VL were screened for HIV infection and 7 of the 111 were found to be positive for HIV. Table 1 shows the clinical picture for these VL cases and for those VL cases coinfected with HIV.TABLE 1: Clinico-biochemical parameters of VL and VL/HIV coinfection casesLeishmania/HIV coinfection is emerging as an extremely serious new disease pattern, and it is becoming increasingly frequent. There are important clinical, diagnostic, chemotherapeutic, epidemiologic, and economic implications (2). Leishmania/HIV coinfections are considered a real threat, especially in southwestern Europe. Of the first 1700 cases of coinfection reported to the World Health Organization (WHO) from 33 countries worldwide up to 1998, 1440 cases were from southwestern Europe: Spain (835), Italy (229), France (259), and Portugal (117). Of 965 cases retrospectively analyzed, 83.2% were males, 85.7% were young adults (20–40 years old), and 71.1% were injection drug users (2). Most coinfections in the Americas are reported in Brazil, where the incidence of AIDS has risen from 0.8 cases per 100,000 inhabitants in 1986 to 10.5 cases per 100,000 inhabitants in 1997 (2). This and other reports of coinfection of VL with HIV in Bihar probably signal the beginning of a new epidemic. It is well known that in India tuberculosis of the lung is a very common opportunistic infection both in HIV-infected persons and in VL-infected persons. The increase in cases of VL with HIV coinfection in Bihar, in conjunction with their association with tuberculosis, is expected to be of great concern for public health. Such cases will be very difficult to treat and large number of drugs that are required to treat the three conditions will have adverse effects and be very costly. However, it has been reported that miltefosine, an oral drug, could be effective for treatment of cases of VL and HIV coinfection. Acknowledgment: The authors thank Mr. Rakesh Bihari Verma, Technical Assistant, and Mr. Gopal Kumar Pankaj, Technician, VCTC, for their assistance in the successful completion of the project.