Abstract
HIV and AIDS affect over 30 million people worldwide, and diarrhea affects 28–60% of HIV-positive patients. Patients who have low CD4 counts (less than 350) are highly susceptible to a range of opportunistic infections. Approximately 50% of patients present with an infectious etiology. HIV/AIDS patients are susceptible to bacterial and parasitic causes of diarrhea – cryptosporidiosis being one of the most difficult to treat. Patients should be counseled that ensuring compliance with their protease inhibitors is key in treating their diarrhea.
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Keywords
FormalPara Pearls and Pitfalls-
Protease inhibitors decrease the risk of infectious diarrhea.
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Cryptosporidiosis is a difficult condition to manage in HIV/AIDS patients.
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Patients, who do not have an infectious etiology, can also be treated with anti-motility and anti-secretory agents for symptom management.
HIV and AIDS affect over 30 million people worldwide, and diarrhea affects 28–60% of HIV-positive patients [1, 2]. Patients who have low CD4 counts (less than 350) are highly susceptible to a range of opportunistic infections. Approximately half of HIV/AIDS patients presenting with diarrhea have an infectious etiology. Noninfectious causes include medication side effects from antiretroviral (ART) therapy, enteropathy from depletion of CD4 T-cell lymphocytes in the gastrointestinal lymphoid tissue, malabsorption from their chronic illness, and malignancies due to the progression of HIV to AIDs [2,3,4,5,6,7]. Due to the destruction of the CD4 T lymphocytes, patients are more susceptible to severe dehydration and malabsorption.
Infectious Considerations for HIV Patients with Diarrhea
Common bacterial etiologies of diarrhea in HIV-positive patients include Campylobacter, Shigella, Salmonella, Escherichia coli, and Clostridium difficile. While often the cause of diarrhea in non-HIV-positive patients, the clinical course can be prolonged and more severe for HIV patients. A brief synopsis of common infectious causes of diarrhea in the HIV population and their treatment is found in Table 102.1.
Cryptosporidiosis is a difficult condition to manage in HIV/AIDS patients. Nitazoxanide has demonstrated no benefit compared to placebo [14]. Though a higher dose and longer treatment course may produce benefit, the drug has not been approved by the FDA in high doses [14]. A Cochrane review supports its use as an option alone or in combination with other antimicrobials as well as emphasizes the importance of immune reconstitution with HAART for curative therapy [15].
Treatment for Noninfectious Causes of Diarrhea
Patients, who do not have an infectious etiology, can also be treated with anti-motility (e.g., loperamide, diphenoxylate, opiates) and anti-secretory agents. However, it is important to counsel patients who are suffering from diarrhea from protease inhibitors that they should continue their medication. Protease inhibitors decrease the risk of infectious diarrhea from 53% to 13% [9, 10]. Patients with chronic diarrhea from HAART should be managed in close consultation with their infectious disease doctor to help mitigate side effects.
Suggested Resource
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Logan C, Beadsworth M, Beeching N. HIV and diarrhea: what is new? Curr Opin Infect Dis. 2016;29(5):486–94.
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Gale, A.R., Wilson, M. (2019). Diarrhea and AIDS. In: Graham, A., Carlberg, D.J. (eds) Gastrointestinal Emergencies. Springer, Cham. https://doi.org/10.1007/978-3-319-98343-1_102
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