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Evaluation of the HIV-infected patient with diarrhea

C Mel Wilcox, MD
Christine A Wanke, MD
Section Editor
John G Bartlett, MD
Deputy Editor
Howard Libman, MD, FACP


Diarrhea can cause significant morbidity in HIV-infected patients and can be due to a multitude of etiologies from infectious pathogens to malignancy to medications. Diarrhea is also an independent predictor of reduced quality of life and, in the case of advanced HIV disease, increased mortality [1].

The approach to the evaluation of diarrhea will be discussed here. For detailed information about specific pathogens, please see appropriate topic reviews. (See "AIDS-related cytomegalovirus gastrointestinal disease" and "Mycobacterium avium complex (MAC) infections in HIV-infected patients".)


United States – Prior to the use of potent antiretroviral therapy (ART) in the United States, chronic diarrhea (defined as four or more weeks of diarrhea) was responsible for 17 percent of the new AIDS diagnoses reported to the Centers for Disease Control and Prevention (CDC) [2]. (See "The natural history and clinical features of HIV infection in adults and adolescents", section on 'AIDS and advanced HIV infection'.)

However, with the widespread use of ART, the incidence of infectious causes of diarrhea in HIV-infected patients with low CD4 counts (<200 cells/microL) has declined [3]. Experience at a single center between 1995 and 1997 found that, while the incidence of diarrhea remained constant, infectious etiologies declined from 53 to 13 percent [4]. In another study that followed a cohort of approximately 600 patients in the Boston area after the introduction of potent ART, chronic diarrhea was reported in 28 percent and severe diarrhea (defined as more than six stools per day) in 3 percent [5]. In this study, stool pathogens were found in only 12 percent of the population.

Although the incidence of infectious diarrhea has decreased, antiretroviral-associated diarrhea may occur in up to 50 percent of patients, depending on the ART regimen (see 'Exposures' below). Medication-induced diarrhea is a leading diagnostic consideration when diarrhea is the sole complaint [6], particularly when there is a temporal association. In addition, when an infectious etiology is not ascertained in advanced disease, then HIV-associated enteropathy needs to be considered.

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Literature review current through: Nov 2017. | This topic last updated: Mar 15, 2017.
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