**6.4 Visceral leishmaniasis**

Traditionally VL has been treated by pentavalent antimonials. Recently there is emergence of resistance in the Indian subcontinent. Current recommendations for VL in East Africa include pentavalent antimonials, LAMB, or combination treatment (including pentavalent antimonials with paromomycin). As for the Indian subcontinent, the recommendations include LAMB, amphotericin B deoxycholate, miltefosine, and one of the combination therapies: LAMB with miltefosine, LAMB with paromomycin, or miltefosine with paromomycin [1]. As for complicated VL, elderly patients, and pregnant patients in East Africa, it is recommended to have LAMB treatment because of its better safety. LAMB monotherapy is not recommended in patients with less severe disease in Asia due to lack of proven efficacy in that region [42]. In Asia, sodium stibogluconate, rather than LAMB, is considered the first-line treatment for *L. infantum* and *L. donovani.* The WHO recommended LAMB therapy in the initial elimination phase for *L. donovani* in


#### **Table 5**.

**6.3 Post-kala-azar dermal leishmaniasis**

*Parasitology and Microbiology Research*

**Table 3**.

**310**

Treatment regimens for PKDL are scant. In general, majority of cases from East Africa are self-healing and therefore do not require treatment. In contrast, in the Indian subcontinent, these patients are treated. Since vast majority of these patients are healthy and the risk is cosmetic, the risk benefit should be weighed before initiating therapy. Selected treatment regimens are recommended by the WHO,

*Treatment regimens for cutaneous leishmaniasis, Old World species, as per WHO recommendations (adopted from WHO) (https://www.who.int/leishmaniasis/research/978924129496\_pp67\_71.pdf?ua=1) [8].*

> *Treatment regimens for post-kala-azar dermal leishmaniasis as per WHO recommendations (adopted from WHO) (https://www.who.int/leishmaniasis/research/978924129496\_pp67\_71.pdf?ua=1) [8].*


the Indian subcontinent; however currently several combination regimens are available which will alleviate the risk of resistance development to LAMB

**6.5 Human immunodeficiency virus (HIV): Visceral leishmaniasis coinfection**

VL should be treated as an opportunistic infection if diagnosed in patients with HIV, warranting lifelong antiretroviral therapy regardless of CD4 count [27]. The core infected patients require longer treatment with higher doses since they are at a higher risk for disease relapse, poor outcome, and increased mortality. In addition, developing VL disease in HIV patients adversely affects their response to antiretroviral therapy [43]. Current WHO recommendation, so far, is LAMB for all regions. Some cases may require combination treatment including LAMB with mitefosine, pentavalent antimonials, and/or amphotericin B deoxycholate. Randomized control trials are ongoing in both Ethiopia and India comparing combination of LAMB and

Surgical intervention is not the recommended modality of treatment in majority of leishmaniasis cases; however, surgery may be required in certain cases such as splenectomy in resistant disease, orofacial surgery for severely debilitating ML, and

*L. donovani* is perhaps one of the most virulent *Leishmania* species and is present in South Asian region, one of the highest incidence areas of VL. Between 2005 and 2013, *Leishmania* ranked the second worst next only to malaria among the 16 categories of "neglected tropical diseases" [46]. In 2005 the WHO and the government representatives of India, Nepal, and Bangladesh signed a memorandum of understanding with commitment to mutually cooperate in order to achieve VL elimination from these countries by 2015. The objective was to reduce the annual incidence of VL to below 1/10,000 inhabitants by 2015 using detection and treatment of VL cases and vector control measures [47]. The target was not achieved by the expected date of 2015 due to high cost and limited availability of treatment, lack of effectiveness of vector control measures, emergence of parasite resistance, and low community coverage of health services in all areas. A second target was set for 2017; however, the WHO has recently reset the target of VL elimination from the Indian subcontinent to year 2020 [48]. In the Eastern Mediterranean region, a specific target was set for CL to detect 70% of all cases and at least treat 90% of them. There is crucial gap in planning elimination of VL in Asia and VL and CL in other regions. These elimination campaigns will require more intense work and better strategic planning in addition to the high cost required. Currently, there is increased global awareness about the disease and the dire need for its elimination, in particular, after Asian elimination initiative of VL and 2012 London declaration on neglected tropical diseases. Having said that, many challenges still exist that counteract these efforts. These include poor sanitary conditions, conflict zones leading to forced migration, emerging atypical variants, poor public awareness especially in nonendemic areas, suboptimal diagnostic modalities, and limited

therapy (**Table 6**) [17, 18].

*DOI: http://dx.doi.org/10.5772/intechopen.90680*

*Leishmaniasis*

**6.6 Surgical intervention**

**7. Prevention and control**

treatment options [1, 49].

**313**

miltefosine with LAMB monotherapy [44, 45].

cosmetic surgery for disfiguring cutaneous lesions.

#### **Table 6**.

*Treatment regimens for visceral leishmaniasis as per WHO recommendations (adopted from WHO) (https:// www.who.int/leishmaniasis/research/978924129496\_pp67\_71.pdf?ua=1) [8].*

the Indian subcontinent; however currently several combination regimens are available which will alleviate the risk of resistance development to LAMB therapy (**Table 6**) [17, 18].
