Human Immunodeficiency Virus-Associated Diarrhea: Still an Issue in the Era of Antiretroviral Therapy

Abstract

Over half of patients with human immunodeficiency virus (HIV) experience diarrhea that contributes negatively to quality of life and adherence to antiretroviral therapy (ART). Opportunistic infectious agents that cause diarrhea in patients with HIV span the array of protozoa, fungi, viruses, and bacteria. With global use of ART, the incidence of diarrhea because of opportunistic infections has decreased; however, the incidence of noninfectious diarrhea has increased. The etiology of noninfectious diarrhea in patients with HIV is multifactorial and includes ART-associated diarrhea and gastrointestinal damage related to HIV infection (i.e., HIV enteropathy). A basic algorithm for the diagnosis of diarrhea in patients with HIV includes physical examination, a review of medical history, assessment of HIV viral load and CD4+ T cell count, stool microbiologic assessment, and endoscopic evaluation, if needed. For patients with negative diagnostic results, the diagnosis of noninfectious diarrhea may be considered. Pharmacologic options for the treatment of noninfectious diarrhea are primarily supportive; however, the use of many unapproved agents is based on unstudied and anecdotal information. In addition, these agents can be associated with treatment-limiting adverse events (AEs), such as drug–drug interactions with ART regimens, abuse liability, and additional gastrointestinal AEs. Currently, crofelemer, an antisecretory agent, is the only therapy approved in the USA for the symptomatic relief of noninfectious diarrhea in patients with HIV on ART.

Antiretroviral Treatment with Efavirenz Disrupts the Blood-Brain Barrier Integrity and Increases Stroke Severity

“…While some of these disorders can be attributed to HIV infection and the ensuing persistent state of inflammation, growing evidence indicates that ARVd toxicity could be at least partially involved in the development of these pathologies. Several side effects, such as lactic acidosis, lipodystrophy, hyperbilirubinemia, diarrhea, pancreatitis, peripheral neuropathy, neuropsychiatric disorders and hypersensitivity, have been linked to the use of ARVd89101112131415161718. HIV protease inhibitors have been associated with proteasome disruption, liver injury, and gut barrier dysfunction19.…”

Untitled

“…Pectin is an effective antidiarrheal agent and together with kaolin it acts as adsorbent resulting in more solid form stool and it also has affinity to attach the digestive mucus and toxins hence aids in reducing water loss 16,17 . The use of kaolin-pectin antidiarrheal preparation is still common in Middle east and Gulf 18 South Africa 19 , Indonesia 16 and Australia 19 (Bis pectin, 2016) Although FDA has discontinued the use of kaolin / pectin suspension early 2000, the use of kaolin pectin as adsorbent has proved effective in the pharmacological treatment of for non-infectious HIV-associated diarrhea 20 .…”

A 10-year-old boy presented with recurrent episodes of diarrhea, low grade, irregular fever and severe wasting

“…If any enteric pathogen is identified, then treatment should be done accordingly. [30][31][32][33][34]…”