Diarrhea and HIV Disease

by Richard S. Ferri, Ph.D., ANP, ACRN, FAAN

Frequent loose stools can be a debilitating side effect of HIV disease and its treatment. Between 50% to 90% of all persons living with HIV will experience diarrhea at some point. It can occur abruptly or chronically and can present with such symptoms as loose stools, abdominal cramping, bloating, fever, and pain.

Diarrhea is typically classified (a) according to its duration, as acute or chronic; or (b) by its type, as secretory, osmotic, or mixed. Acute diarrhea has an abrupt onset, lasts for less than a week, and is often associated with nausea, vomiting, and fever. When diarrhea lasts longer than a month, it is termed chronic. Secretory diarrhea results from fluids that secrete into the gastrointestinal (GI) tract from crypt cells. Osmotic diarrhea occurs when a positive fluid gradient is created as a result of unabsorbed fluid in the GI tract. Mixed diarrhea is the combination of both the secretory and osmotic types.

The etiology of diarrhea in HIV disease is multifactorial and helps guide treatment. Secretory diarrheas etiology is usually infectious in nature and can result from viral, bacterial, or protozoal pathogens. Osmotic diarrhea occurs when there is a presence of fatty acids from fat malabsorption, hypertonic medications or formula, or sorbital in the GI lumen.

Evaluation of diarrhea should examine the patients recent dietary, travel, medication, and mental health histories. In addition, objective data should include an abdominal exam to assess for bowel sounds, tenderness, or distention. Clinicians should also assess for any lesions or tissue breakdown in the perianal area. Hydration status is important, and any presence of postural hypotension, tachycardia, or poor skin turgor should be noted. Stool studies should look at the consistency of the stool and any presence of blood, pus, mucus, fat, or parasites in the sample. If all diagnostic studies are negative, one may need to consider endocscopy and/or sigmoidoscopy to rule out any malignancies or opportunistic infections.

The prevention of diarrhea is of primary importance in treating persons with HIV disease. Basic appropriate food handling and hand washing can greatly reduce some of the enteric pathogens that result in diarrhea. Dehydration occurs when the body has lost too much fluid and electrolytes (the salts potassium and sodium). The fluid and electrolytes lost during diarrhea need to be replaced promptlythe body cannot function properly without them. Dehydration is particularly dangerous for children, who can die from it within a matter of days. Although water is extremely important in preventing dehydration, it does not contain electrolytes. To maintain electrolyte levels, you could have broth or soups, which contain sodium, and fruit juices, soft fruits, or vegetables, which contain potassium. For children, doctors often recommend a special rehydration solution that contains the nutrients they need. You can buy this solution in the grocery store without a prescription. Examples include Pedialyte, Ceralyte, and Infalyte.

Patients should also be counseled about the need to eat small meals every two to three hours and to avoid fats and reduce or eliminate lactose, alcohol, and caffeine intake. Foods that are easy to digest such as peeled, cooked fruits and vegetables, bananas, applesauce, cooked cereal, and rice should be included in the diet. Until diarrhea subsides, try to avoid milk products and foods that are greasy, high-fiber, or very sweet. These foods tend to aggravate diarrhea. As you improve, you can add soft, bland foods to your diet, including bananas, plain rice, boiled potatoes, toast, crackers, cooked carrots, and baked chicken without the skin or fat. For children, the pediatrician may recommend what is called the BRAT diet: bananas, rice, applesauce, and toast.

Travelers diarrhea happens when you consume food or water contaminated with bacteria, viruses, or parasites. You can take the following precautions to prevent travelers diarrhea when you go abroad:

" Do not drink any tap water, not even when brushing your teeth.
" Do not drink unpasteurized milk or dairy products.
" Do not use ice made from tap water.
" Avoid all raw fruits and vegetables (including lettuce and fruit salad) unless they can be peeled and you peel them yourself.
" Do not eat raw or rare meat and fish.
" Do not eat meat or shellfish that is not hot when served to you.
" Do not eat food from street vendors.

You can safely drink bottled water (if you are the one to break the seal), carbonated soft drinks, and hot drinks like coffee or tea. Depending on where you are going and how long you are staying, your doctor may recommend that you take antibiotics.

Pharmacological management of diarrhea may include such agents as loperamide (Imodium®) or diphenoxylate (Lomotil®) in adequate amounts at regular intervals. However, sometimes a stronger agent is needed such as tincture of opium, paregoric, or oral opiates. Traditional Chinese Medicine interventions to treat diarrhea include acupuncture and Chinese herbs and may concern hotcold food theories.

Diarrhea can be a vexing clinical problem with complicated clinical outcomes including weight loss, dehydration, and development of poor body image. Also, persons living with HIV may fear traveling from home since they will not be near a bathroom; they can suffer social isolation and miss doses of antiretroviral medications.

Dr. Ferri received his Masters of Science in PrimaryHealth Care Nursing, Adult Nurse Practitioner, from Simmons College and Ph.D. in Adult Education and Development from Columbia Pacific University, and a master of science in adult educationand human resource development from Fordham University in New York. He is certified as an AIDS Certified Registered Nurse (ACRN) and has served the elected positions of president and national director for the Association of Nurses in AIDS Care (ANAC) the HIV/AIDS Nursing Certification Board (HANCB) from 19992000. He currently practices in an independent consulting firm in the areas of HIV/STD clinical management and lends his expertise to continuing medical and nursing education program development, editing, writing, and scripting for multi disciplinary audiences, workshops/seminars in HIV/STD management, mens health issues, gay and lesbian issues (domestic violence, breast cancer, prostate disease), and adolescent health care.

Dr. Ferri has co-authored eight textbooks and written more than 40 articles in such journals as RN, Nursing Spectrum, The American Journal of Nursing, The Journal of the Association of Nurses in AIDS Care, and Advance for Nurse Practitioners. He is on the editorial board/review panel of several professional journals, he has presented at more than 35 national symposia and workshops. Dr. Ferri is a Distinguished Lecturer in HIV/AIDS Nursing for the ANAC. He is a clinical expert in HIV nursing for the International Council of Nurses, and is a Fellow of the American Academy of Nursing. In November of 2000, he was awarded the ANAC Lifetime achievement award for this contributions to AIDS care.