After treating more than 13,000 patients suffering from kala azar in Bihar since 2007, Doctors Without Borders/Médecins Sans Frontières (MSF) is now focusing on the diagnosis and treatment of HIV-kala azar co-infection. Dr Deepak Kumar, who has been working with MSF since 2009, spoke to us about this emerging global problem and why we need to address it.
- We understand that MSF was providing services to treat Kala azar in Hajipur, Bihar, and the project was handed over to the state authorities last year. Could you please tell the readers about the project?
India accounts for around 50 per cent of the global burden of kala azar (visceral leishmaniasis), and 90 per cent of these cases are found in Bihar. Recognising this need, MSF began its work in Bihar in 2007 by setting up a kala azar ward in Sadar Hospital in Hajipur, Vaishali district, Bihar, and providing support to five primary health centres (PHCs) in the same district. In September 2014, following important safety evidence from an MSF-Drugs for Neglected Diseases initiative (DNDi) pilot study, the first-line treatment for kala azar in India was changed to a single dose of liposomal amphotericin B (LAmB) in the national policy. Till date, the project has treated more than 13,000 patients. After a successful handover of its primary kala azar treatment project to the state health authorities in August 2015, MSF began focusing on treating kala azar-HIV co-infection in 2016, and is currently located in Rajendra Memorial Research Institute of Medical Sciences (RMRIMS) in Patna.
- The project also specifically focused on post kala azar dermal leishmaniasis (PKDL). Could you please tell us what PKDL is and how MSF treats it?
PKDL is a cutaneous and muco-cutaneous disease and defined as pre-, para-, and post-dermal leishmaniasis. PKDL in India manifests as cutaneous eruptions which develop within a duration of six months to two years after the treatment of kala azar. PKDL of the cutaneous form (prevalent in India) presents as macular, papular, nodular, erythromatious eruptions in patients with past history of kala azar.
PKDL is treated by infusing six doses of Liposomal Amphotericin B (LAMB) over a period of three weeks. Each dose comprises 5 mg/kg b.w. of LAMB.
- MSF is now conducting operational research on kala azar-HIV co-infection at RMRIMS in Patna. Could you please elaborate on kala azar-HIV co-infection? What is it? What are the symptoms? How is it diagnosed and treated?
Kala azar-HIV coinfection is an emerging global problem; in India, it is endemic to the state of Bihar, where there is a high prevalence of both kala azar as well as HIV. Kala azar patients who are co-infected with HIV are at a greater risk of death because both the pathogens reinforce each other in causing immunosuppression to the infected. Patients with HIV are much more likely to develop kala azar, while kala azar accelerates HIV replication and progression to end-stage disease.
The symptoms of kala azar are recurring high fever, loss of appetite (early satiety), loss of weight, weakness, fatigue, low haemoglobin, and an enlarged spleen.
Primary kala azar is diagnosed by the rK16 rapid diagnostic test (RDT); for relapse cases of kala azar, parasitological confirmation (L.D. bodies) is obtained through splenic aspiration/bone marrow aspiration. Patients with kala azar who show symptoms of HIV are referred to designated ART centres where they undergo counselling as well.
The treatment for kala azar-HIV co-infection is different from that of primary kala azar because in co-infected patients relapse of kala azar tends to be the rule rather than the exception.
The current WHO recommended treatment for kala azar-HIV co-infection is 40 mg/kg b.w. of AmBisome in eight equal 5 mg/kg b.w. doses over 24 days. Combination treatment of AmBisome with miltefosine has shown initial promising results and further evaluation to find the best treatment for this highly vulnerable population is in progress. This endeavour will help in formulating up-to-date evidence-based treatment guidelines.
- Why is MSF focusing on kala azar-HIV co-infection?
MSF is focusing on kala azar-HIV co-infection because relapse and mortality rates are around 13 -14 times higher in comparison to cases of kala azar without HIV. Kala azar can also not be completely eliminated without addressing the kala azar-HIV co-infection. So while cases of primary kala azar are going down, the proportion of co-infections are on the rise, which presents a public health challenge and needs to be addressed comprehensively.
- What is MSF’s model of care for kala azar-HIV co-infection?
The model of care for kala azar-HIV is as follows:
a) Co-ordination with MoH at state and district level.
b) Advocating for HIV testing for all kala azar patients due to differences in treatment regimens, and testing for kala azar in all people living with HIV.
c) Strengthening of information, education and communication (IEC) activities in different districts.
d) Management of kala azar-HIV co-infected patients and enabling easier access to our treatment.
- Is there a particular reason why RMRIMS in Patna was chosen as the location for this study?
RMRIMS is a premier academic institution in Bihar (and a unit of Indian Council of Medical Research) and shares MSF’s goal of generating evidence for the optimal treatment of kala azar in HIV co-infected patients. This will help in the aim to eliminate kala azar in India.
- What are some of the challenges you anticipate while collecting data for the study? How are you planning to counter these challenges?
The biggest challenge is ensuring awareness among healthcare providers across the state about the latest guidelines in the management of kala azar-HIV co-infection and why it is so important to identify and treat such patients.
- What is MSF’s expectation from the outcome of the study? When are they expected?
MSF’s expectation from the outcome of the study is to provide evidence to decision makers at the national and regional levels regarding treatment for kala azar-HIV co-infection. This will then feed into the national road map of kala azar elimination from India while providing quality healthcare to a highly vulnerable population.
This study is expected to commence in early 2017 and the preliminary results are expected to be out in a year’s time.
To know more about MSF’s latest medical research click here
 National Roadmap for Kala azar Elimination 2014, Directorate of National Vector Borne Disease Control Programme, Directorate General of Health Services, Ministry of Health and Family Welfare, 2014. Source: http://nvbdcp.gov.in/Doc/Road-map-KA_2014.pdf
 Sundar et al, Household cost-of-illness of visceral leishmaniasis in Bihar, India, Research gate, 2010. Source: https://www.researchgate.net/publication/44616066_Household_cost-of-illness_of_visceral_leishmaniasis_in_Bihar_India