Action needed to tackle co-infection with HIV and visceral leishmaniasis in India

Michael Carter
Published: 20 May 2014

HIV and visceral leishmaniasis co-infection is “an under-diagnosed and under-recognised emerging public health issue in the Indian context requiring urgent action,” according to research published in the online edition of Clinical Infectious Diseases.

Approximately 5% of people diagnosed with visceral leishmaniasis (VL) were living with HIV, and 2.5% of individuals had previously undiagnosed HIV. The findings are described as “a wake-up call” by the author of an accompanying editorial.

Visceral leishmaniasis (also known as kala-azar) is caused by a parasitic infection transmitted by the bite of certain kinds of female sandflies. The infection is associated with frequent bouts of high fever, weight loss, anaemia and swelling of the liver and spleen. If untreated, the mortality rate in developing countries can reach 100% over two years.

Co-infection with HIV and visceral leishmaniasis is a recognised public health challenge in Africa. Both infections are also endemic in the Indian state of Bihar. However, little is known about the prevalence of HIV and visceral leishmaniasis co-infection in the Indian context.

Investigators from MSF (Médecins Sans Frontières) therefore designed a retrospective study involving 2077 people aged 14 years and older who were newly diagnosed with visceral leishmaniasis in Bihar between 2011 and 2013. Voluntary HIV testing and counselling was offered to all these patients (98% accepted). The investigators looked at the overall prevalence of HIV and visceral leishmaniasis co-infection and also the prevalence of previously undiagnosed HIV infection.

Overall, 117 of the participants in the study (4.5%) were HIV positive. Of these, 68 had previously been diagnosed with HIV, meaning that 49 people (2.4%) were newly diagnosed. The investigators focused their analysis on these patients.

A higher proportion of males than females (35 vs 14; 1.5 higher-fold risk) had previously undiagnosed HIV infection. However, the difference was not statistically significant.

The prevalence of co-infection was highest among males in the 35 to 45 age group. “When pooled with data on the numbers already diagnosed HIV-positive presenting with VL to the programme, altogether 12.8% and 6.1% of all 35-45 year old males and females, respectively, were co-infected,” comment the authors.

Co-infection was associated with an increased risk of severe anaemia (p < 0.001) and previous infection with visceral leishmaniasis (p < 0.001). People with HIV co-infection were also more likely to be malnourished and have larger spleen size, but the differences with HIV-negative patients did not reach significance.

“Missed HIV diagnoses lead to worse outcomes from both the patient and the public health perspective,” write the authors. “Early detection of HIV improves long-term prognosis for VL patients, since initiation of ART has been shown to reduce mortality and VL relapse rates in India and elsewhere.”

They conclude that awareness of the relationship between HIV and visceral leishmaniasis needs to be increased and that “multi-disciplinary diagnosis and treatment guidelines and training modes for health care providers” are required.


Burza S et al. HIV and visceral leishmaniasis co-infection in Bihar, India: an under-recognised and under-diagnosed threat against elimination. Clin Infect Dis, online edition, 2014.

Van Griensven J et al. Visceral leishmaniasis and HIV co-infection in Bihar, India: a wake-up call? Clin Infect Dis, online edition, 2014.

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