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Management of Buruli Ulcer–HIV Coinfection

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Management of Buruli Ulcer–HIV Coinfection Management of Buruli ulcer–HIV coinfection Technical update Contents Acknowledgements iv Key learning points 1 Background 2 Guiding principles of management 5 Recommended treatment for Buruli ulcer with HIV coinfection 7 Research agenda 12 References 14 © World Health Organization 2015 All rights reserved. Publications of the World Health Organization are available on the WHO website (www. who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: [email protected]). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO website (www.who.int/about/licensing/ copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. WHO/HTM/NTD/IDM/2015.01 BURULI ULCER–HIV cOINFECTION Areas of Africa endemic for Buruli ulcer (BU), caused by Mycobacterium ulcerans, also have a high prevalence of human immunodeficiency virus (HIV), with adult prevalence rates between 1% and 5%. However, there is a lack of information on the prevalence of BU–HIV coinfection. Further study is needed to clarify this association and enhance knowledge about the prevalence of BU–HIV coinfection in endemic areas. Management of Buruli ulcer–HIV coinfection Technical update iii Management of Buruli ulcer–HIV coinfection iv Acknowledgements WHO would like to thank the following • Serge Mathurin Kaboré people for their contributions to the MSF-Switzerland, Yaoundé, development of this document: Cameroon • Anatole Kibadi • Yaw Amoako Faculté de Médecine, Université Komfo Anokye Teaching Hospital, de Kinshasa, Democratic Kumasi, Ghana Republic of the Congo • Edwin Ampadu • Charles Kouanfack Ghana Health Service, Accra, Ghana Hôpital Central de Yaoundé, • Kingsley Asiedu Cameroon WHO Department of Control of • Johnny Lujan Neglected Tropical Diseases, Geneva, MSF-Switzerland, Geneva, Switzerland Switzerland • Henry Asse • Lisa Nelson Buruli ulcer control programme, WHO Department of HIV/AIDS, Abidjan, Côte d’Ivoire Geneva, Switzerland • Alexandra Calmy • Daniel O’Brien University of Geneva, Switzerland The Geelong Hospital, Victoria, • Annick Chauty Australia Buruli ulcer Treatment Hospital, • Albert Paintsil Pobe, Benin Korle-Bu Teaching Hospital, • Vanessa Christinet Accra, Ghana University of Geneva, Switzerland • Delphin Phanzu • Eric Comte Institut Médical Evangélique, MSF-Switzerland, Geneva, Kimpese, Democratic Republic of Switzerland the Congo • Meg Doherty • Richard Phillips WHO Department of HIV/AIDS, Komfo Anokye Teaching Geneva, Switzerland Hospital, Kumasi, Ghana • Serge Eholie • Gerd Pluschke University Hospital, Abidjan, Côte Swiss Tropical and Public Health d’Ivoire Institute, Basel, Switzerland • Nathan Ford • Francoise Portaels WHO Department of HIV/AIDS, Institute of Tropical Medicine, Geneva, Switzerland Antwerp, Belgium • Haileyesus Getahun Gebre • Fred Sarfo WHO Global TB Programme, Komfo Anokye Teaching Geneva, Switzerland Hospital, Kumasi, Ghana v Management of Buruli ulcer–HIV coinfection • Micaela Serafini MSF-Switzerland, Geneva, Switzerland • Ghislain Sopoh Buruli ulcer Treatment Hospital, Allada, Benin • Ymkje Stienstra University Medical Center Groningen, Netherlands • Marco Vitoria WHO Department of HIV/AIDS, Geneva, Switzerland • Mark Wansbrough-Jones St George’s Hospital Medical School, London, UK • Dorothy Yeboah-Manu Noguchi Memorial Institute for Medical Research, Accra, Ghana vi Key learning points • ART should be initiated in all BU– • All Buruli ulcer (BU) patients should be HIV coinfected patients with advanced offered high-quality provider-initiated symptomatic HIV disease (WHO HIV testing and counselling. clinical stage 3 or 4) regardless of CD4 cell-count and in those asymptomatic • Cotrimoxazole prophylaxis should be individuals with CD4 count ≤ 500 cells/ 3 commenced immediately for all HIV mm . If CD4 cell-count is not available, patients with a CD4 count ≤ 350 cells/ BU–HIV coinfected individuals with mm3, or if CD4 count is not available and WHO category 2 or 3 BU disease should the patient has advanced symptomatic be offered ART. HIV disease (WHO clinical stage 3 or 4). In settings with high prevalence • For eligible individuals, ART should be of malaria and/or severe bacterial commenced as soon as possible within 8 infections, cotrimoxazole prophylaxis weeks after commencing BU treatment should be initiated in all and as a priority in those with individuals regardless of advanced HIV disease (CD4 ALL BURULI ULCER 3 CD4 cell-count. ≤ 350 cells/mm or WHO (BU) PATIENTS clinical stage 3 or 4 disease). • Combination antibiotic SHOULD BE treatment for BU should be OFFERED HIGH- • All BU–HIV coinfected commenced before starting patients should be actively antiretroviral therapy (ART) QUALITY PROVIDER- screened for tuberculosis and given for 8 weeks’ INITIATED HIV before commencing BU duration. The recommended TESTING AND treatment and before starting combination is rifampicin plus ART. streptomycin. An alternative COUNSELLING. regimen is rifampicin plus • Programmes should clarithromycin, although due implement a monitoring and to drug interactions this regimen should reporting system to monitor and evaluate be used with caution. the outcomes of BU–HIV interventions. 1 Management of Buruli ulcer–HIV coinfection Background in Benin and Ghana, BU patients were 8 times and 4 times respectively more likely to Areas of Africa endemic for Buruli ulcer have HIV infection than those without BU (BU), caused by Mycobacterium ulcerans, (1,2). Further study is needed to clarify this also have a high prevalence of human association and enhance knowledge about immunodeficiency virus (HIV), with adult the prevalence of BU–HIV coinfection in prevalence rates between 1% and 5% (Maps). endemic areas. However, there is a lack of information on the prevalence of BU–HIV coinfection. HIV may affect the clinical presentation Preliminary evidence suggests that HIV and severity of BU disease, with a reported infection may increase the risk of BU disease increased incidence of multiple, larger (1–3). In the Médecins Sans Frontières and ulcerated BU lesions in HIV-infected project in Akonolinga, Cameroon, HIV individuals (3–6). Additionally in the prevalence was approximately 3–6 times Akonolinga project, the main lesion size was higher among BU patients than the regional significantly increased with decreasing CD4 estimated HIV prevalence (3). Similarly cell-count levels (3). Distribution of Buruli ulcer, worlwide, 2013 2 Adult HIV prevalence (15–49 years), 2011, by WHO region Prevalence (%) by WHO region Africa South-East Asia Americas Eastern Mediterranean Europe Western Pacific Global Prvalence : 0.8% The boundaries and names shown and the designations used on this map do not imply the expression Data Source: World Health Organization of any opinion whatsoever on the part of the World Health Organization concerning the legal status Map Production: Control of Neglected of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers Tropical Diseases (NTD) or boundaries. Dotted lines on maps represent approximate border lines for which there may not World Health Organization yet be full agreement. © WHO 2014. All rights reserved Little is known about the impact of HIV on BU treatment outcomes, such as mortality, cure, recurrence, time to healing, long-term disability and the incidence of paradoxical AREAS OF AFRICA reactions secondary to antibiotic treatment. ENDEMIC FOR BURULI The Akonolinga project reported that ULCER (BU), CAUSED the mortality rate in BU–HIV coinfected patients treated for BU without antiretroviral BY MYCOBACTERIUM therapy (ART) was significantly higher ULCERANS, ALSO than for HIV non-infected BU patients havE A HIGH (11% vs 1%, P < 0.001) (3). The median CD4 cell-count at baseline among the eight PREvaLENCE OF HUMAN deceased HIV patients was 228.5 cell/mm3 IMMUNODEFICIENCY (IQR 98–378 cells/mm3); the median time to death from BU diagnosis was short (41.5 VIRUS (HIV), WITH ADULT days, IQR 16.5–56.5 days). Additionally in PREvaLENCE RATES BU–HIV coinfected patients, ulcer healing BETWEEN 1% AND 5% took longer in those with CD4 levels below 500 cells/mm3. These findings need further confirmation in other
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