The direct agglutination test (DAT) is not the only diagnostic test used in the program we described.1 Even if a case of VL and HIV coinfection was missed by DAT, the diagnostic algorithm used in Ethiopia would still identify it, because in the case of a negative DAT result, but persisting signs and symptoms of VL, a splenic aspiration is indicated. DAT is used as a first-line test to reduce the number of tissue aspirates required for screening clinically suspicious cases.
The results from European studies cannot be extrapolated to African VL, because the patient characteristics are quite different. For example, in the study by Pintado and colleagues,2 which Subhash Arya and Nirmala Agarwal refer to, patients were mainly injection drug users who were profoundly immunocompromised. An evaluation of DAT in Ethiopian patients with VL (with and without HIV infection) concluded that in contrast to the observations made in Europe, DAT in Ethiopia remains reasonably sensitive in diagnosing VL during HIV coinfection.3 These findings are confirmed by unpublished data from the Médecins Sans Frontières miltefosine study in Kafta Humera Woreda, which show that DAT titres in cases of HIV coinfection did not differ from those in cases where there was no coinfection, that is, there was no shift in the mean and distribution of DAT titres.
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