Diarrhea is one of the most common problems for HIV+ people. It can affect as much as 80 percent of the HIV+ population. Unfortunately, this is one problem that has not gotten better since people started using combinations of HIV drugs.

Many factors can cause diarrhea. Some of these include:

• HIV virus damaging the gut (intestines) – particularly if you have a high viral load or a low CD4 count
• Parasites living in the gut
• Bacterial or viral infections
• HIV drugs (especially protease inhibitors)
• Anxiety
• Antibiotics or other medicines

When you have diarrhea, your body loses fluid and you can become dehydrated. In addition to water your body also loses minerals called electrolytes, such as sodium and potassium.

It is important to keep drinking plenty of clean, safe water, fruit juices (100% fruit juice), and broth. You can replace electrolytes by drinking juices or non-caffeinated sodas that you have allowed to go flat, or by eating broth, gelatin, and popsicles. If your dehydration is severe you may need to drink sports drinks like Gatorade or PowerAde. (However, small children with diarrhea should not drink sports drinks but should get special fluids like Pedialyte™ or Enfalyte™)

Diarrhea can also lead to malnutrition (not getting enough nutrients from your food). Diarrhea sometimes prevents food from staying in your gut long enough for your body to absorb the nutrients it needs. Also, if your gut is damaged by the virus, it cannot absorb very well. That means that you will not be getting important vitamins, minerals, protein, and calories from your food.

Having diarrhea can also make you not want to eat. When you do not eat because you do not want to have diarrhea, you are at risk for malnutrition.

Even though it may be embarrassing to talk about, it is important to tell your doctor if you have diarrhea so he or she can find the cause and recommend appropriate treatments.

Before your diarrhea can be treated, you must figure out what is causing it.  Diarrhea is caused by several different things. If an infection or parasite is the cause, you must get rid of the infection or parasite before the diarrhea will clear up.

If HIV drugs are causing your diarrhea, it may clear up after you’ve been on those drugs for a couple of weeks. Talk to your doctor before you start a new drug to find out if diarrhea is a possible side effect. If so, ask what anti-diarrhea treatments to get ahead of time, so that you will have them in case you need them.

Also talk to your doctor about seeing a nutritionist. A nutritionist can help you choose foods that will make diarrhea less likely to occur, or more manageable if it does occur.

Certain alternative or natural medicines may help diarrhea. These include herbs containing berberine (golden seal, barberry, and Oregon grape), chamomile tea, marshmallow root, and slippery elm.

Diet Changes:

• Eat small meals at room temperature every two to three hours
• Make sure you drink lots of fluids and replace electrolytes
• Try not to eat high fat or greasy meals, especially fried foods
• Avoid fat substitutes like olestra
• If you have gas or stomach pains, try not to eat gas-forming foods like onions, beans, broccoli, cabbage, and cauliflower
• Spicy foods and very sweet foods may make gas and diarrhea worse
• Stay away from caffeine - caffeine is found in coffee, sodas, and chocolate
• Eat soluble fiber in foods like oats & oatmeal, potatoes, white rice, and apples (without the peel)
• Avoid insoluble fiber, or “roughage,” which is found in lettuce, greens, bran, seeds, whole grain breads, and corn
• Avoid eating raw or undercooked foods (such as meat, fish, chicken and eggs) or un-pasteurized dairy products

Sometimes the BRATT diet can help:

• B ananas
• R ice (white)
• A pples (without peels), applesauce, or juice
• T oast (white)
• T ea (herbal, not sweet iced tea)

After your diarrhea clears up you may slowly return to a normal, healthy diet.  However, you may want to start with more bland foods like bananas, plain rice, boiled potatoes, baked chicken (with skin and fat removed), eggs, plain toast, and crackers.

Other Tips:

• Keep a diary of food and other things you feel might trigger your diarrhea and discuss this with your physician and dietitian
• Wash fruits and vegetables before eating
• Wash your hands often and thoroughly
• Ask your doctor about a referral to a gastrointestinal specialist if diarrhea does not go away

In some cases a nutritional supplement may help reduce diarrhea. Make sure to ask your HIV doctor first; do not just start taking them on your own. Some of these supplements include:

• L-glutamine: 10-30 grams per day. This supplement is often helpful if your diarrhea is caused by HIV drugs. You may want to try mixing the powder in juice or applesauce several times a day
• Calcium carbonate: 500 milligrams twice a day. Researchers are not sure how much this supplement actually helps diarrhea, but in most cases it doesn’t hurt to try. It is thought that calcium carbonate helps the most if your diarrhea is caused by Viracept (nelfinavir) or Kaletra (lopinavir+ritonavir).
• Probiotics: these are the “good bacteria” normally found in your gut. They usually need to be refrigerated, and may contain acidophilus or bifidus. They can also be found in yogurts and milks containing “live active cultures.” Probiotics are often used if your diarrhea is caused by taking antibiotics, but they can work for other types of diarrhea, too
• Both over-the-counter and prescription drugs are available to treat diarrhea, depending on the cause. Talk to your doctor about what’s right for you

Remember, diarrhea is manageable. It may take several tries to figure out what works for you, but do not give up! If necessary, your HIV regimen can even be changed, but do not just stop your HIV drugs. With the help of your doctor and dietitian, you can find the best options for managing or eliminating your diarrhea.

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2		Jensen-Fangel, S., et al. (2003). The use of calcium carbonate in nelfinavir-associated diarrhea in HIV-1 infected patients. HIV Medicine 4(1). 48.
3		Acute Diarrhea Patient Handout. McKesson Clinical Reference Systems Patient Education Advisors. Accessed at http://www.merckmedicus.com/pp/us/hcp/hcp_patient_resource_allhandouts_content_search.jsp?pg=/ppdocs/us/common/crs/wha/wha_acudiarr_crs.htm on 06/08/2006.
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