18
64. The Panel recommends administering secondary prophylaxis (chronic
maintenance therapy) to decrease the risk for posttreatment relapse
of VL in persons with HIV/AIDS-associated immunosuppression (eg,
CD4 T-lymphocyte cell counts <200 cells/mm
3
) (S-M).
65. Persons with VL-HIV/AIDS coinfection should be monitored
indefinitely (until effective immune reconstitution) for evidence of
posttreatment relapse. ART and secondary prophylaxis provide only
partial protection against relapse. Antileishmanial treatment is
indicated for persons who have clinical and parasitologic evidence of
recurrence (S-L).
HIV/AIDS-ASSOCIATED CL or ML in North America
66. In HIV/AIDS-associated CL/ML, systemic antileishmanial therapy
is recommended, particularly in persons who are moderately to
severely immunosuppressed (eg, have CD4+ T-lymphocyte cell
counts <200–350 cells/mm
3
), who may be at increased risk for
suboptimal therapeutic responses, for posttreatment relapses, and
for cutaneous, mucosal, or visceral dissemination (S-VL).
67. The systemic regimens used for CL/ML in otherwise comparable
immunocompetent persons typically are recommended for the initial
treatment of coinfected persons, taking into account the potentials
for drug interactions and toxicity (Tables 3 and 4) (S-VL).
Remark: Whether coinfected persons who experience multiple posttreatment relapses
of CL/ML would benefit from secondary prophylaxis (chronic maintenance therapy)
has not yet been established.
68. Antiretroviral therapy (ART) should be initiated or optimized in
accordance with standard practice for HIV/AIDS; no evidence-
based, CL/ML-specific recommendations regarding ART have been
established (S-L).
Immunocompromised Hosts With Solid Organ Transplant,
Persons With Lymphatic-Hematologic Malignancies, or
Persons Receiving Immunosuppressive Therapy for Other
Reasons
69. Liposomal amphotericin B (L-AmB) is recommended as the drug of
choice for immunosuppressed persons with VL (Table 3) (S-L).
Remarks: The FDA-approved regimen is 4 mg/kg/day IV on days 1–5, 10, 17, 24,
31, and 38 (total dose of 40 mg/kg ). Higher doses and longer durations of therapy
may be needed depending in part on the level of immunosuppression.
70. Doses of immunosuppressive drugs should be decreased in persons
with VL during antileishmanial therapy whenever possible (S-VL).
Treatment
