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Diarrhea is frequent among persons infected with human immunodeficiency virus (HIV) but few interventions are available for people in Africa. We conducted a randomized controlled trial of a home-based, safe water intervention on the incidence and severity of diarrhea among persons with HIV living in rural Uganda. Between April 2001 and November 2002, households of 509 persons with HIV and 1,521 HIV-negative household members received a closed-mouth plastic container, a dilute chlorine solution, and hygiene education (safe water system [SWS]) or simply hygiene education alone. After five months, HIV-positive participants received daily cotrimoxazole prophylaxis (160 mg of trimethoprim and 800 mg of sulfamethoxazole) and were followed for an additional 1.5 years. Persons with HIV using SWS had 25% fewer diarrhea episodes (adjusted incidence rate ratio [IRR] = 0.75, 95% confidence interval [CI] = 0.59–0.94, P = 0.015), 33% fewer days with diarrhea (IRR = 0.67, 95% CI = 0.48–0.94, P = 0.021), and less visible blood or mucus in stools (28% versus 39%; P < 0.0001). The SWS was equally effective with or without cotrimoxazole prophylaxis (P = 0.73 for interaction), and together they reduced diarrhea episodes by 67% (IRR = 0.33, 95% CI = 0.24–0.46, P < 0.0001), days with diarrhea by 54% (IRR = 0.46, 95% CI = 0.32–0.66, P < 0.0001), and days of work or school lost due to diarrhea by 47% (IRR = 0.53, 95% CI = 0.34–0.83, P < 0.0056). A home-based safe water system reduced diarrhea frequency and severity among persons with HIV living in Africa and large scale implementation should be considered.
Received April 27, 2005. Accepted for publication July 11, 2005.
Acknowledgments: We thank the Tororo Hospital administrative and clinical staff; the volunteers, staff, and clients of TASO; the U.S. Embassy in Kampala; Global AIDS Program headquarters, Atlanta, GA; the staff of CDC-Uganda, including the informatics, clinical, laboratory, and administrative units of CDC-Tororo for their participation in this study. The staff of CDC was involved in the study design, data collection, analysis, and writing of the report. John R. Lule was the main author of the paper. John R. Lule, Jonathan Mermin, and Robert Quick were the principal investigators who wrote the protocol, supervised the study, guided data analysis, had full access to all the data, and take responsibility for the integrity of the data and accuracy of data analysis. Raymond Ransom supervised data entry and cleaning. John Paul Ekwaru and Samuel Malamba analyzed data and conducted statistical analyses. Robert Downing, Peter Hughes, and Aminah Kigozi supervised and conducted laboratory testing. Damalie Nakanjako and Winnie Wafula provided clinical oversight for the study. Rebecca Bunnell assisted in the design of the study, and she and Frank Kaharuza provided guidance in conducting the study and interpreting results. Alex Coutinho helped in designing and conducting the study, and ensured the protocol was applicable to TASO.
Financial support: This study was supported by CDC.
Disclosure: None of the authors had any conflicts of interest.
* Address correspondence to John R. Lule, Centers for Disease Control and Prevention-Uganda, Entebbe, Uganda. E-mail: nzl4{at}cdcuganda.org
Authors’ addresses: John R. Lule, Jonathan Mermin, John Paul Ekwaru, Samuel Malamba, Robert Downing, Raymond Ransom, Damalie Nakanjako, Winnie Wafula, Rebecca Bunnell, Frank Kaharuza, and Aminah Kigozi, Centers for Disease Control and Prevention-Uganda, Entebbe, Uganda and Global AIDS Program, National Center for HIV, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA 30333. Peter Hughes, Uganda Virus Research Institute, Entebbe, Uganda and Medical Research Council Programme on AIDS in Uganda, Entebbe, Uganda. Alex Coutinho, The AIDS Support Organization, Entebbe, Uganda. Robert Quick, Foodborne and Diarrheal Diseases Branch, Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30333.
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