1. The role of secondary prophylaxis in the management of HIV-VL co-infection: 7-years experience from West Bengal
Prof. Rama Prosad Goswami,
Department of Tropical Medicine,
School of Tropical Medicine,
Kolkata, India

2. Introduction

3. HIV-VL - Indian scenario
Before 2002 – a single case report (C P Thakur et al, Trans R Soc Trop Med Hyg, 2000)
2003 – cases reported increasingly
Prevalence – 1.5% (C P thakur et al,JAIDS2003)
- 6.3% (P K Sinha et al,JAIDS 2003)
Sakib Burza et al, CID HIV screening of 2077 VL patients in Bihar - 5.6% were HIV positive including 2.4% with newly diagnosed HIV infection.

4. VL & HIV both depresses cellular immunity Co-infection results in:
Accelerated progression of VL
Treatment failure
Repeated relapse
Drug toxicity
Increased mortality

5. Methods

6. 2-year outcome of 24 co-infected patients admitted to the CSTM between 2007 and 2014 were analysed
Retrospective hospital based observational study
Hospital records were reviewed
Ethical approval waived by the IEC, STM, Kolkata

7. Results

8. Hospital records of past 7 years showed admissions of:
4459 HIV
408 VL
24 VL-HIV
( VL patients diagnosed to be HIV infected after admission)

10. Baseline characteristics
Parameters
HIV/VL (n = 24)
VL (n = 120)
P - value
Mean age (SD)
38 (8)
17.5 (12.9)
<0.001
Male: n (%)
19/24 (79.16)
60/120 (50)
0.008
Spleen size cm (SD)
10.2 (3.7)
11.8 (5.4)
0.17
Mean Hb in Gm/dL (SD)
7.1 (2.3)
8.6 (1.1)
Mean TLC/μL (SD)
3425 (1457)
3210 (1280)
0.46
Hepatomegaly: n (%)
23/24 (95.83)
115/120 (95.83)
0.99
Liver size in cm (SD)
4.3 (1.7)
2.6 (2.5)
0.01
rK39 positivity in serum
22/24 (91.66)
118/120 (98.3)
0.06
rK39 positivity in urine
0.43
Mean CD4 at baseline (SD)
121 (84)
N/A
CD4 < 200/μL
21/24 (87.5)
Diarrhoea
2/24 (8.3)
0.001
Cough and shortness of breath
1/24 (4.1)
0.02

11. Treatment Outcome Amphotericin B – total dose 20 mg/kg
14 patients – Lyophilised amphotericin B
10 patients – Liposomal amphotericin B
End of Treatment cure rate – 96% (23)
1 patient died while on treatment (associated TB & Toxoplasmosis)
HAART started after completion of total dose

12. Effect of secondary prophylaxis
Monthly amphotericin B (1mg/kg)
12 patients (52%)
Effect of secondary prophylaxis on outcome of VL/HIV co – infected patients
Outcome measures
Secondary prophylaxis
(n = 12)
No secondary prophylaxis
(n = 11)
P – value
Relapse
8 (72.7%)
<0.001
Death
5 (45.5%)
<0.01

13. Secondary prophylaxis N = 12 CD4: 122 (104)
VL/HIV
N = 23
Secondary prophylaxis
N = 12
CD4: 122 (104)
6 month cure rate
N = 12 (100%)
CD4: 180 (89)
12 and 24 months cure rate
CD4: 378 (85)
No prophylaxis against VL
N = 11
CD4: 126 (107)
6 month cure
N = 3 (27.3%)
CD4: 175 (76)
12 months cure rate
CD4: 248 (98)
At least one relapse
8/11 (72.7%)
CD4: 108 (45)
Lost to follow up
N = 3
Multiple relapses within the first year and death
N = 5 (45.5%)
2 stopped ART

14. Cox regression for hazard ratio of death
Secondary prophylaxis: HR: 0.007, 95% CI: – 0.153, p – value: 0.007
Baseline CD4: HR: 0.99, 95% CI: 0.98 – 1.01, p – value: 0.07

15. Limitations of the study
Retrospective analysis / Small cohort size
Data were not computerised – detailed clinical and laboratory data of every patient were not available: some data had to be eliminated from analysis
Some of the deaths in “No secondary prophylaxis” may be due to other associated infection because of declining CD4 count – detailed investigations were not always available

16. Burza S et al. PLOS NTD, 2014 159 VL/HIV IV AmBisome (20–25 mg/kg)
HAART 23 (14.5%), 39 (24.5%) and 61 (38.4%) before, during and after admission respectively.
Initial cure: 153/159
Death: 36/159 (22.64%)
Relapse: 26/153 (16.9%)
Mortality association:
anaemia and concurrent TB
Reduced risk of mortality with ART initiation

17. What do we learn... VL/HIV is increasing
It is quite deadly....deadlier than VL at least
Early initiation of ART appears to be a promising tool
Secondary prophylaxis against VL needs to be considered with seriousness with generation of evidences against opposition of eminences
We need larger studies

18. Thanks for your patience