The document discusses a case of a 59-year-old woman with chronic HIV experiencing diarrhea and abdominal symptoms, highlighting that over half of HIV patients suffer from diarrhea due to various causes including infections and medications. It details the mechanisms of HIV enteropathy and the impact of antiretroviral therapy (ART) on gastrointestinal health while emphasizing the importance of managing symptoms through hydration and modifications to ART. Additionally, it reviews preventative measures and features recommendations from the World Health Organization regarding the treatment and prevention of diarrhea in HIV-positive patients.

1. College of Medicine and Health
Sciences
Diarrhea in AIDS patients

2. A 59-year-old woman with chronic HIV infection presents with a one-
week history of diarrhea associated with mid-abdominal cramps,
bloating, generalized pain and weakness. She describes six to eight
loose bowel movements daily. Her most recent CD4 count is 0.22 ×
109/L, with an undetectable viral load. Her current antiretroviral (ARV)
regimen consists of ritonavir-boosted atazanavir, tenofovir and
emtricitabine.

3.  Over half of patients with human immunodeficiency virus
(HIV) experience diarrhea that can cause significant
morbidity and can be due to a multitude of etiologies from
infectious pathogens to malignancy to medications.
 Diarrhea remains a common complaint among these
patients and continues to negatively impact the quality of
life and adherence to antiretroviral therapy (ART) .

4.  Worldwide, the most common causes of diarrhea in HIV-
infected patients are enteric bacteria including Shigella
flexneri, Salmonella enteritidis and Campylbacter jejuni .
 Cytomegalo virus (CMV), cryptosporidiosis,
microsporidia and Mycobacterium avium complex (MAC)
become important pathogens when immunodeficiency is
advanced.

5.  AIDS-related neoplasms such as Kaposi’s sarcoma
or lymphoma and fungi rarely cause diarrhea.
 There is also non-infectious diarrhea in patients
with HIV which is multifactorial and includes ART-
associated diarrhea and gastrointestinal damage
related to HIV infection (i.e., HIV enteropathy)

6. Gut-associated lymphoid tissue (GALT) is the largest
collection of lymphoid tissue in the human body. The
gastrointestinal (GI) tract is regularly exposed to a complex
and diverse assortment of antigens from both microbial and
dietary sources. As a result, naïve B and T cells of the gut are
constantly interacting with antigens that induce their
maturation into plasma cells and memory T cells,
respectively.
This persistent stimulation of the immune system leads to a
baseline inflammatory state that encourages the production
of chemokines and adhesion molecules, which mediate the
movement of lymphocytes into the mucosal tissues, resulting

7.  Regarding non-infectious diarrhea, HIV has been
postulated to alter signaling and cellular structure, which
may lead to architectural distortion. Several studies have
demonstrated crypt epithelial proliferation in response to
HIV infection, leading to increased crypt height,
subsequent crypt cell encroachment onto villi, and relative
decreased villous height resulting in diarrhea and
malabsorption.
 Other hypotheses for the mechanism of HIV enteropathy
include decreased transepithelial electrical resistance,
decreased sodium-dependent glucose absorption, and
increased intercellular permeability in HIV-infected cells.

8.  And regarding ART-Associated Diarrhea, Diarrhea is an
adverse effect of ART, protease inhibitors seem to be most
strongly associated with diarrhea

9. This figure illustrates the
common causes of
diarrhea at different
stages of HIV infection
and treatment.
The shaded
boxes indicate causes of
diarrhea at different
stages of HIV infection
based on CD4+ T cell
count. The impact of
starting ART on CD4+ T
cell counts is depicted by
the gray dotted line.

10.  Rehydration via intravenous and oral routes, repletion of
electrolytes.
 Empiric antibiotic therapy with a quinolone
and metronidazole
 Noninfectious diarrhea can be managed by modifying ART
and controlling symptoms with medications and lifestyle
modification.
 ColoPlus® IMCARE has been proven to alleviate diarrhea
and sustain weight gain in HIV-infected individuals.

11.  The current WHO guidelines recommend co-trimoxazole
prophylaxis for persistent diarrhoea in HIV-positive
patients.
 And Application of key measures to prevent
diarrhoea which include use of improved sanitation, hand
washing with soap, good personal and food hygiene,…

12.  https://www.aidsmap.com/news/dec-2004/who-guidelines-treatment-diarrhoea-hiv-patients-
may-need-revising-some-settings-
says#:~:text=Current%20WHO%20guidelines%20recommend%20co,erythromycin%20were%20all%
20widely%20effective.
 https://www.slideshare.net/ShimaGh/diarrhea-61105934/2
 https://www.uptodate.com/contents/evaluation-of-the-patient-with-hiv-and-
diarrhea?source=bookmarks_widget#H12120099
 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4499110/#:~:text=Over%20half%20of%20patient
s%20with,fungi%2C%20viruses%2C%20and%20bacteria.
 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4723481/
 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3218691/