Clinical Features of Human Immunodeficiency Virus–Infected Patients Presenting with Cholera in Port-au-Prince, Haiti

Abstract

Abstract. Human immunodeficiency virus (HIV) infection has been postulated to alter the natural history of cholera, including increased susceptibility to infection, severity of illness, and chronic carriage of Vibrio cholerae. Haiti has a generalized HIV epidemic with an adult HIV prevalence of 1.9% and recently suffered a cholera epidemic. We conducted a prospective study at the cholera treatment center (CTC) of GHESKIO in Haiti to characterize the coinfection. Adults admitted at the CTC for acute diarrhea were invited to participate in the study. Vital signs, frequency, and volume of stools and/or vomiting were monitored, and single-dose doxycycline was administered. After counseling, participants were screened for HIV by enzyme-linked immunosorbent assay and for cholera by culture. Of 729 adults admitted to the CTC, 99 (13.6%) had HIV infection, and 457 (63%) had culture-confirmed cholera. HIV prevalence was three times higher in patients without cholera (23%, 63/272) than in those with culture-confirmed cholera (7.9%, 36/457). HIV prevalence in patients with culture-confirmed cholera (7.9%) was four times higher than the adult prevalence in Port-au-Prince (1.9%). Of the 36 HIV-infected patients with cholera, 25 (69%) had moderate/severe dehydration versus 302/421 (72%) in the HIV negative. Of 30 HIV-infected patients with weekly stool cultures performed after discharge, 29 (97%) were negative at week 1. Of 50 HIV-negative patients with weekly stool cultures, 49 (98%) were negative at week 1. In countries with endemic HIV infection, clinicians should consider screening patients presenting with suspected cholera for HIV coinfection.

Risk Factors for Self-Reported Cholera Within HIV-Affected Households in Rural Haiti

“…Although cholera is not typically regarded as an opportunistic infection, little is known about the clinical features or risk of cholera in the setting of HIV infection, a disease with substantial geographic overlap with cholera [ 1 , 3 ]. In 1 study, 13.6% of people presenting over the course of a year to a CTC in urban Haiti were found to be HIV-infected, as compared with an estimated 1.9% adult HIV prevalence in that region [ 4 ]. Half as many HIV-infected individuals as those without HIV infection ultimately had a positive stool culture for cholera, indicating that other causes of diarrhea may have contributed to some presentations.…”

“…There are other potential factors that may contribute to an association between HIV and a reported history of cholera. In some cases, other causes of diarrhea related to HIV infection may have been misattributed to cholera, as suggested by the previously mentioned study, which found a discrepancy in the rate of positive stool culture for V. cholerae between HIV-infected and uninfected individuals presenting with acute watery diarrhea [ 4 ]. The HIV-infected participants in that study, however, had a median CD4 count of 222 cells/mm 3 , and nearly two-thirds were newly diagnosed with HIV at the time of presentation.…”

“…However, the clinical features and risk of cholera among HIV-infected people and their households have not been well characterized. One recent study in urban Haiti found a higher than expected prevalence of HIV among people presenting to a cholera treatment center (CTC) with diarrhea [ 4 ], and 2 case–control studies also suggest a possible association between HIV and cholera, although both were at high risk of selection bias [ 5 , 6 ].…”

Cholera: A Latent Threat to Human Health

“…Unexpectedly, reduced host immunity, as seen in people suffering from acquired immunodeficiency syndrome (AIDS), did not affect the severity of cholera but might be associated with a higher risk of infection. This was exemplified in Port-au-Prince, Haiti, where the prevalence of HIV infection in patients with cultureconfirmed cholera was four times higher than the adult prevalence in the region (14).…”