Reducing Persistent Diarrhea for People Living with HIV/AIDS by Use of Effective Household Water Treatment Approaches

T. Mahin1 , R. Peletz2 , M. Eliott3 , M. Sackey Harris4

1 Massachusetts Dept. of Environmental Protection 2 London School of Hygiene and Tropical Medicine 3 UNC - Chapel Hill, UNC Water Institute 4 UNC - Chapel Hill, Institute for Global Health & Infectious Diseases

Presented at Water and Health 2012 Chapel Hill, NC, USA

Definitions

Persistent Diarrhea (PD) – Generally defined as

diarrhea lasting > 14 days

Chronic Diarrhea (CD) – Generally defined as

diarrhea lasting > 30 days, therefore CD is a

subcategory of PD

PLHA – People Living with HIV/AIDS

ART – Anti Retroviral Therapy

Background

PLHA are 4-7 times more likely to have diarrhea compared to HIV-negative individuals (Mermin 2004)

Persistent and chronic diarrhea associated with increased mortality for PLHA

Household water treatment (HWT) increasingly recommended for PLHA

To what extent do recommended HWT technologies address pathogens of concern?

Impact of PD/CD on Mortality Rates for PLHA not on ART

Persistent diarrhea (PD) is associated with increased mortality for PLHA not on ARTs.

- Sewankambo 2000 (Uganda) & Chintu 1998 (Zambia)

46% of eligible PLHA not on ART (end of 2011).

UNAIDS 2012

Chronic Diarrhea, PLHA & Mortality (Uganda)

Adapted from Sewankambo et al. AIDS 2000

Chronic Diarrhea & Mortality Risk for PLHA (Zambia)

“The HIV-associated chronic diarrhea was associated

with weight loss, malnutrition, and excess mortality.”

Chintu et al. 1998 J. Trop. Med. Hyg., 59(1), pp. 38–41

PD/CD at ART Initiation Impact on Mortality Rates

PD/CD at ART initiation has been associated with

increased early mortality in a number of low &

middle income countries

A meta-analysis of adults initiating ART examined

causes of early mortality (Gupta 2011)

Chronic

diarrhea

TB Wasting Advanced HIV

10-20% 5-44% 5-53% 20-37%

Approach Used for This Review

Searched PUBMED & IAS Online Resource Library for studies on waterborne pathogens for PLHA with PD/CD in low- or middle-income countries

Determined which waterborne pathogens were most commonly detected by taking the % of PLHA-PD for each pathogen in each study & then averaging

studies

Compared results to HWT efficacy in treating most common pathogens detected

Overview of Studies (low & middle income countries)

PD cases from 10 to 1,800

Region Africa Asia Lain

America

Middle

East

Total

Number of studies 18 17 9 2 46

Study Design Cross-

sectional

HIV+ controls (w/o

diarrhea or PD/CD)

HIV-

controls

Controls of

unclear HIV

status

Number of studies 28 12 5 1

% Positive (all data for low/mid Income countries)

10

Symptomatic Asymptomatic

Waterborne Pathogen No. PD

Studies

Mean % Range Mean % Range

Cryptosporidium 40 27% (3 – 74%) 9% (0-50%)

Microsporidia 22 21% (0 -77%) 5% (0-25%)

Isospora 28 13% (1-41%) 2% (0-6%)

Cyclospora 13 8% (1-34%) <1% 0-2%

Salmonella 13 8% (0-19%) 6% (0-17%)

E. Histolytica 14 7% (0-23%) 4% (0-20%)

Giardia 24 7% (0-22%) 6% (0-16%)

Shigella 10 7% (0-22%) 3% (1-5%)

Rotavirus 2 7% (5-8%) 2% (0-3%)

Campylobacter 7 5% (0-13%) 0% -

11

Waterborne Pathogen

Infection Rates for

PLHA-PD by Region

Africa

(SSA)

%

Asia

%

Latin America

& Caribbean

%

Middle

East

%

Cryptosporidium 30 20 33 39

Microsporidia 26 21 13 9

Isospora 10 14 15 4

Cyclospora 3 6 34 -

Salmonella 10 7 1 -

E. histolytica 9 8 6 4

Giardia 7 6 9 9

Shigella 12 3 4 -

Rotavirus - 5 8 -

Campylobacter 6 5 4 -

Cryptosporidium

AIDS defining illness

PLHA suffered most from Crypto outbreaks in the

USA (Hoxie 1997, Goldstein 1996)

Smaller than Isospora & Cyclospora oocysts

(implications for HWT filtration)

Chlorine is ineffective at inactivating Crypto but

other methods are effective (WHO 2011a)

Microsporidia

Microsporidia are zoonotic parasites with resistant

spores than can be transmitted by water, are

currently unregulated by USEPA & are now

proposed for identification as fungi

Microsporidia spores are smaller than

Cryptosporidium oocysts (filter implications)

Microsporidia are moderately susceptible to

chlorine (WHO 2011b, Li & Fayer 2006, Johnson 2003, Wolk 2000)

and flocculation/settling appears to work well (Gerba

2003)

Mortality Risk

Microsporidia are likely a significant cause of

chronic diarrhea for PLHA but based on very

limited data Microsporidia may be less of a PLHA

mortality risk than Cryptosporidium (Bern et al. 2005).

Cryptosporidium infection for PLHA with PD was

associated with increased mortality in 3 of the PD

studies in this review that looked at this issue

(Amadi 2001, Mwachari 1998 & Tumwine 2005).

Preliminary Recommended HWT Approaches for PLHA with PD in Low/Middle- Income

Countries

Treatment needs to address pathogens of

concern, including:

Boiling

Use of a household water filter (e.g. ceramic,

biosand, carbon block) followed by chlorination,

Use of a flocculant/disinfectant powder along with

proper settling/decanting.

Conclusions •Waterborne pathogens are associated with PD/CD

in PLHA in low- and middle- income countries

• Cryptosporidium & Microsporidia most commonly

detected and associated with increased mortality

•Very limited data on viruses

•Microsporidia are an emerging pathogen associated

with CD, particularly for PLHA with low CD4 counts

•HWT treatment (and other WASH interventions)

need to address pathogens of greatest concern

Upcoming Reviews

Systematic review of enteric infections among PLHA

in sub-Saharan Africa

Systematic review of WASH interventions to improve

health of PLHA

References Cited Amadi et al. 2001 J. Pediatr Gastoenterol Nutr.

Bern et al. 2005 The Journal of Infect. Diseases 191

Chintu et al. 1998 J. Trop. Med. Hyg., 59(1)

Gerba et al. 2003 J Environ Sci Health A Tox Hazard Subst

Environ Eng. Jul;38(7)

Gupta et al. 2011 PLoS ONE Dec.

Johnson et al. 2003 APPLIED & ENVIRONMENTAL MICROBIOLOGY

Li and Fayer 2006 J Eukaryot. Microbiol., 53(S1)

Mwachari et al. 1998 J Infect. July

Rajagopalan et al. 2009 Am J Infect Dis. 5(3)

Sewankambo et al. 2000 AIDS

Tumwine et al. 2005 Am J Trop Med Hyg.

Wolk et al. 2000 Appl Environ Microbiol. Apr;66(4)

WHO 2011a “Evaluating household water treatment options heath-

based targets and microbiological performance specifications”

WHO 2011b - Guidelines for Drinking-water Quality Fourth Edition

WHO 2012 - HIV/AIDS Fact sheet No. 360, July 2012

Comparison of Data with Data from High-Income Countries

An additional 15 studies were found of PD in PLHA

in high-income countries (HICs).

Microsporidia infection rates averaged 25% for HICs

vs. 20% for low/mid-income countries (LMICs),

Cryptosporidium rates were 19% for HICs vs.

27% for LMICs.

All HIC studies were from the 1990s & results may

be different now given higher ART use rates in HICs.