What is the management approach for diarrhea in an individual with Human Immunodeficiency Virus (HIV)?

Management of Diarrhea in HIV Patients

The management of diarrhea in HIV patients requires a comprehensive diagnostic evaluation to identify the cause, followed by targeted treatment based on etiology, with rehydration and nutritional support as essential components of care regardless of cause. 1

Diagnostic Approach

• Evaluate severity of diarrhea including frequency, volume, presence of blood, and associated symptoms like fever or dehydration 2
• Assess for warning signs requiring immediate medical attention: high fever, bloody stools, severe dehydration, or symptoms persisting >48 hours 2
• Determine CD4+ T cell count and HIV viral load to assess immune status and guide diagnostic considerations 1, 3
• Obtain stool samples for microbiologic assessment, including examination for:
  • Parasites (especially Cryptosporidium and Isospora belli) 4
  • Bacterial pathogens (including Salmonella, Shigella, Campylobacter) 1
  • Viral pathogens 5
• Consider endoscopic evaluation if initial diagnostic workup is negative or if symptoms persist despite empiric therapy 1, 3

Etiology-Based Management

Infectious Diarrhea

• For Salmonella gastroenteritis, consider antimicrobial therapy to prevent extraintestinal spread, particularly in severely immunosuppressed patients 1
• Fluoroquinolones (primarily ciprofloxacin 750 mg twice daily for 14 days) are recommended for susceptible organisms 1
• For HIV-exposed infants <3 months and severely immunosuppressed children, administer treatment for Salmonella gastroenteritis with appropriate antibiotics (TMP-SMZ, ampicillin, cefotaxime, or ceftriaxone) 1
• For patients with Salmonella septicemia, long-term therapy (secondary prophylaxis) is required to prevent recurrence 1

Non-Infectious Diarrhea

• Consider antiretroviral therapy (ART) as a potential cause, particularly protease inhibitors which may damage intestinal epithelial barrier 6, 7
• Evaluate for HIV enteropathy, which results from direct effects of HIV on gastrointestinal tract cells 6, 5
• Monitor for malabsorption of antiretroviral medications, which may lead to subtherapeutic drug levels and treatment failure 4
• For symptomatic relief, antiperistaltic agents such as loperamide can be used with important cautions:
  • Discontinue if symptoms persist >48 hours 1, 2
  • Avoid in patients with high fever or bloody stools 1, 2
  • Not recommended for children 1, 2
• Consider crofelemer, the only FDA-approved therapy for symptomatic relief of non-infectious diarrhea in HIV patients on ART 3, 7

Supportive Care

• Ensure adequate hydration with oral rehydration solutions approaching WHO-recommended electrolyte concentrations (e.g., Ceralyte, Pedialyte) 1, 2
• For severe dehydration, administer intravenous fluids 1
• Monitor for electrolyte imbalances and correct as needed 2
• Provide nutritional support to prevent wasting 4

Prevention Strategies

Food and Water Safety

• Avoid raw or undercooked eggs, poultry, meat, or seafood 1
• Avoid unpasteurized dairy products 1
• Thoroughly wash produce before consumption 1
• Prevent cross-contamination by washing hands, cutting boards, counters, and utensils after contact with uncooked foods 1
• Avoid soft cheeses and ready-to-eat foods (e.g., hot dogs, cold cuts) due to risk of listeriosis 1

Travel Precautions

• When traveling to developing countries, avoid:
  • Raw fruits and vegetables 1
  • Raw or undercooked seafood or meat 1
  • Tap water and ice made with tap water 1
  • Unpasteurized milk and dairy products 1
  • Items sold by street vendors 1
• Safe food and beverage options include:
  • Steaming-hot foods 1
  • Fruits peeled by the traveler 1
  • Bottled (especially carbonated) beverages 1
  • Hot coffee and tea, beer, wine 1
  • Water brought to a rolling boil for 1-2 minutes 1
• Consider antimicrobial prophylaxis for HIV-infected travelers based on level of immunosuppression and region/duration of travel 1
• Provide antimicrobial agents (e.g., ciprofloxacin 500 mg twice daily for 3-7 days) to be taken empirically if severe traveler's diarrhea occurs 1

Special Considerations

• For household contacts of HIV-infected persons with salmonellosis or shigellosis, evaluate for persistent asymptomatic carriage to prevent recurrent transmission 1
• Avoid contact with pets that have diarrhea and reptiles (e.g., snakes, lizards, turtles) due to risk of salmonellosis 1
• Wash hands after handling pets, especially before eating 1
• For children, supervise handwashing after pet contact 1