Current opinion on the management of diarrhea in the HIV infected individual

Diarrhea is one of the main reasons for morbidity and mortality in patients with HIV, especially in low and middle-income countries. We review updates on approach, diagnosis and management of diarrhea in patients with HIV.

Duration of symptoms, characteristics of the diarrhea as small-bowel or large-bowel type, presence of constitutional symptoms and current CD4 + cell count are the most important parameters to be noted in the history, and give important clues to diagnosis. Multiple pathogens can co-exist in severely immune compromised patients. Stool microscopy with modified AFB and trichrome stains, though standard, have been largely replaced by multiplex PCR, except in resource limited settings. Computerized tomography scans are helpful when there are constitutional symptoms; and endoscopic biopsy remains the gold standard when noninvasive tests are nondiagnostic. Diagnostic workup can be negative in a subset of the HIV population, which could be due to antiretroviral agents or HIV per se. Treatment involves replacement of fluids & electrolytes and etiology-appropriate antimicrobials. ART should be optimized in all patients, and itself often results in clinical improvement.

Managing chronic diarrhea in HIV positive patients requires a multimodal approach, but is usually successful even in resource-limited settings provided access to ART is available.