Diarrhoea is still one of the most common health problems for people with HIV.
When planning treatment, a good starting point is to decide, if possible, what’s causing it. The first thing to check for is bad gut bugs such as Giardia or Blastocystis. Organisms like Giardia can respond to straightforward medical drugs but sometimes these will give only partial results. Some organisms, such as Blastocystis, have no satisfactory medical treatment. Unfortunately, stool tests for gut bugs aren’t 100 percent reliable.
Natural therapy approaches are more long-term and use a combined strategy. The first step is altering the gut environment so it doesn’t support the growth of parasites and bad bacteriaA microscopic organism composed of a single cell. Many bacteria can cause disease in humans. – the key here is a change in diet, with a particular focus on reducing simple carbohydrates and sugars. ‘Friendly’ gut bugs, such as acidophilus and lactobacillus, are also of great assistance.
Next, we try to increase the immune system’s clearance of the ‘unfriendly’ gut bugs. The medicinal herb Andrographis is very useful here as it stimulates immune function and has a long history of successful use against illnesses such as dysentery.
Finally, there are natural therapies designed to directly kill off pathogenic gut bugs – combinations of herbs such as garlic, Chinese wormwood, walnut hulls or cloves are often chosen to have a direct, destructive effect on gut pathogens. Note that garlic can interfere with some antiretroviralA medication or other substance which is active against retroviruses such as HIV. drugs so check with your doctor before using.
The therapeutic yeast Saccharomyces boulardii is particularly effective. S. boulardii has been used for more than 30 years to successfully treat a wide range of gut problems such as preventing and treating travellers’ diarrhoea and diarrhoea caused by antibiotics1[2][3][4] plus it has a good track record with people with HIV and has been the subject of some trials5[6][7].
S. boulardii is sold in Australia as ‘SB Flor Activ’ but you’ll probably have to get it from a naturopath as very few health food stores stock it.
For people taking anti-HIV drugs, a more common cause of diarrhoea is treatment side effects.
Fibre supplements, such as psyllium husks, slippery elm powder or rice or oat bran are all useful. However, high doses of fibre taken long-term can reduce absorption of key minerals from your diet.
Calcium supplements have performed well in some trials for protease inhibitor-related diarrhoea8. A good starting amount is 500mg twice a day, but higher doses may be needed for a short time9. If you’re taking calcium for a while, take some magnesium as well to keep these two minerals in balance.
Digestive enzymes can be useful when other treatments fail as lab trials show that drugs such as amprenavir, ritonavir, nelfinavir, lopinavir/ritonavir (Kaletra) and saquinavir cause malabsorption of fat10. If fats or oils in your diet cause digestive problems, try a course of pancreatic enzymes. Make sure they contain lipase, the enzyme that digests fats.
Sometimes, people with HIV may have chronic diarrhoea that is not directly caused by either bad gut bugs or drug side effects.
One thing to try in this situation is to stop drinking coffee. Giving up coffee can be difficult, but around 70 percent of people with chronic diarrhoea report improvement after doing so.
The amino acid glutamine can be an indispensable part of an anti-diarrhoea program. It’s effective in healing damaged or weakened mucosal linings of the gut. A good dose to start with is 30 grams per day (about six big, heaped teaspoons). Take two teaspoons, on an empty stomach, dissolved in warm water, three times a day. Some people need more – up to 50 grams per day – to get results, after which they can reduce the dose.
Irrespective of the cause, a combination approach typically gets the best results. For example, 28 men who had nelfinavir or Kaletra-associated diarrhoea began taking 1.2g/day of an acidophilus-bifidus mix plus 11g/day of psyllium fibre (Metamucil)[11]. If this didn’t work after four weeks they began 30g/day of glutamine. Diarrhoea completely resolved for 10 out of 28 (36 percent) of those in this study; the other participants also had significant improvements.
If these approaches fail, food intolerances should be suspected. One that is often unsuspected is intolerance to gluten. It’s hard to spot because gluten is in so many foods – in wheat, barley, rye and oats as well as some less common grains. A trial of 30 people with HIV who all had unexplained, long-term diarrhoea found that switching to a gluten-free diet reduced bowel movements from an average of seven a day down to 2.6 per day within one week (p=.006)[12]. Maintaining a gluten-free diet is difficult, so it’s best to get expert advice before trying this.
Jim Arachne is the Complementary TherapyA broad range of healing philosophies, approaches, and therapies that Western (conventional) medicine does not commonly use to promote well-being or treat health conditions. Examples include acupuncture, herbs, Traditional Chinese Medicine, etc. Treatment Officer for the Victorian AIDS Council.
References:
1 Kotowska M. et al. Saccharomyces boulardii in the prevention of antibiotic-associated diarrhoea in children: a randomized double-blindA clinical trial design in which neither the participating individuals nor the study staff knows which participants are receiving the experimental drug and which are receiving a placebo (or another therapy). Double-blind trials are thought to produce objective results, since the expectations of the doctor and the participant about the experimental drug do not affect the outcome; also called double-masked study. placebo-controlledA method of investigation of drugs in which an inactive substance (the placebo) is given to one group of participants, while the drug being tested is given to another group. The results obtained in the two groups are then compared to see if the investigational treatment is more effective in treating the condition. trial. Aliment Pharmacol Ther. 2005 Mar 1;21(5):583-90.
2 Mansour-Ghanaei F et al. Efficacy(Of a drug or treatment). The maximum ability of a drug or treatment to produce a result regardless of dosage. A drug passes efficacy trials if it is effective at the dose tested and against the illness for which it is prescribed. In the standard procedure, Phase II clinical trials gauge efficacy, and Phase III trials confirm it. of Saccharomyces boulardii with antibiotics in acute amoebiasis. World J Gastroenterol. 2003 Aug;9(8):1832-3.
3 Kirchhelle A et al. [Treatment of persistent diarrhea with S. boulardii in returning travelers. Results of a prospective study] [Article in German]. Fortschr Med. 1996 Apr 20;114(11):136-40.
4 Kollaritsch H. [Prevention of traveller’s diarrhoea with Saccharomyces boulardii. Results of a placeboA dummy medical treatment, designed to have no pharmacological effect, administered to the control group of a clinical trial. controlled double-blind study] [Article in German]. Fortschr Med. 1993 Mar 30;111(9):152-6.
5 Saint-Marc T; et al. 6th Int Conf AIDS. 1990 Jun 20-23;6(1):212 (abstract no. Th.B.363)
6 Born P. et al. [The Saccharomyces boulardii therapy of HIV-associated diarrhoea] [Article in German]. Dtsch Med Wochenschr. 1993 May 21;118(20):765.
7 Saint-Marc T. [Efficacy of Saccharomyces boulardii in the treatment of diarrhoea in AIDS] [Article in French]. Ann Med Interne (Paris). 1991;142(1):64-5.
8 Perez-Rodriguez E, et al. The role of calcium supplements in the treatment of nelfinavir-induced diarrhea. 39th Interscience Conference on Antimicrobial Agents and Chemotherapy; September 26-29, 1999; San Francisco, California. Abstract 1308.
9 Rachlis A, et al. Step-wise intervention for the management of nelfinavir-associated diarrhea. 2nd IAS conference on pathogenesis and treatment, 13-16 July 2003, Paris.
10 TM Wignot. et al. Scientific rationale for the co-administration of highly active antiretroviral therapy and bicarbonate-buffered pancrelipase to treat highly active antiretroviral therapy induced diarrhoea. 4th International Workshop on Adverse Drug Reactions and Lipodystrophy in HIV abstract 62 AntiviralA medication or substance which is active against one or more viruses. May include anti-HIV drugs, but these are more accurately termed antiretrovirals. Therapy 2002; 7:L42
11 Heiser CR. Probiotics, soluble fiber, and L-Glutamine (GLN) reduce nelfinavir (NFV)- or lopinavir/ritonavir (LPV/r)-related diarrhea. J Int Assoc Physicians AIDS Care (Chic Ill). 2004 Oct-Dec;3(4):121-9.
12 Haiko Nellen et al. Treatment of human immunodeficiency virusA small infective organism which is incapable of reproducing outside a host cell. enteropathy with a gluten-free diet. Archives of Internal Medicine; Jan 24, 2000; 160, 2; p. 244.
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