Volume 73, Issue 5
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645


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, = 0.015), 33% fewer days with diarrhea (IRR = 0.67, 95% CI = 0.48–0.94, = 0.021), and less visible blood or mucus in stools (28% versus 39%; < 0.0001). The SWS was equally effective with or without cotrimoxazole prophylaxis ( = 0.73 for interaction), and together they reduced diarrhea episodes by 67% (IRR = 0.33, 95% CI = 0.24–0.46, < 0.0001), days with diarrhea by 54% (IRR = 0.46, 95% CI = 0.32–0.66, < 0.0001), and days of work or school lost due to diarrhea by 47% (IRR = 0.53, 95% CI = 0.34–0.83, < 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.


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  1. Grant AD, Djomand G, De Cock KM, 1997. Natural history and spectrum of disease in adults with HIV/AIDS in Africa. AIDS 11 (Suppl B): S43–S54. [Google Scholar]
  2. Colebunders R, Francis H, Mann JM, Bila KM, Izaley L, Kimputu L, Behets F, van der Groen G, Quinn TC, Curran JW, 1987. Persistent diarrhea, strongly associated with HIV infection in Kinshasa, Zaire. Am J Gastroenterol 82 : 859–864. [Google Scholar]
  3. Brink AK, Mahe C, Watera C, Lugada E, Gilks C, Whitworth J, French N, 2002. Diarrhea, CD4 counts and enteric infections in a community-based cohort of HIV-infected adults in Uganda. J Infect 45 : 99–106. [Google Scholar]
  4. Kaplan JE, Hu DJ, Holmes KK, Jaffe HW, Masur H, De Cock KM, 1996. Preventing opportunistic infections in human immunodeficiency virus-infected persons: implications for the developing world. Am J Trop Med Hyg 55 : 1–11. [Google Scholar]
  5. Reiff FM, Roses M, Venczel L, Quick R, Witt VM, 1996. Low-cost safe water for the world: a practical interim solution. J Public Health Policy 17 : 389–408. [Google Scholar]
  6. Mintz ED, Reiff FM, Tauxe RV, 1995. Safe water treatment and storage in the home: a practical new strategy to prevent water-borne disease. JAMA 273 : 948–953. [Google Scholar]
  7. Quick RE, Venczel LV, Mintz ED, Soleto L, Aparicio J, Gironaz M, Hutwagner L, Greene K, Bopp C, Maloney K, Chavez D, Sobsey M, Tauxe RV, 1999. Diarrhoea prevention in Bolivia through point-of-use water treatment and safe storage: a promising new strategy. Epidemiol Infect 122 : 83–90. [Google Scholar]
  8. Quick RE, Kimura A, Thevos A, Tembo M, Shamputa I, Hutwagner L, Mintz E, 2002. Diarrhea prevention through household-level water disinfection and safe storage in Zambia. Am J Trop Med Hyg 66 : 584–589. [Google Scholar]
  9. Semenza JC, Roberts L, Henderson A, Bogan J, Rubin CH, 1998. Water distribution system and diarrheal disease transmission: a case study in Uzbekistan. Am J Trop Med Hyg 59 : 941–946. [Google Scholar]
  10. Wiktor SZ, Sassan-Morokro M, Grant AD, Abouya L, Karon JM, Maurice C, Djomand G, Ackah A, Domoua K, Kadio A, Yapi A, Combe P, Tossou O, Roels TH, Lackritz EM, Coulibaly D, De Cock KM, Coulibaly IM, Greenberg AE, 1999. Efficacy of trimethoprim-sulphamethoxazole prophylaxis to decrease morbidity and mortality in HIV-1-infected patients with tuberculosis in Abidjan, Cote d’Ivoire: a randomised controlled trial. Lancet 353 : 1469–1475. [Google Scholar]
  11. Anglaret X, Chene G, Attia A, Toure S, Lafont S, Combe P, Manlan K, N’Dri-Yoman T, Salamon R, 1999. Early chemo-prophylaxis with trimethoprim-sulphamethoxazole for HIV-1-infected adults in Abidjan, Cote d’Ivoire: a randomised trial. Cotrimo-CI Study Group. Lancet 353 : 1463–1468. [Google Scholar]
  12. Zachariah R, Spielmann MP, Harries AD, Gomani P, Bakali E, 2002. Cotrimoxazole prophylaxis in HIV-infected individuals after completing anti-tuberculosis treatment in Thyolo, Malawi. Int J Tuberc Lung Dis 6 : 1046–1050. [Google Scholar]
  13. Joloba ML, Bajaksouzian S, Palavecino E, Whalen C, Jacobs MR, 2001. High prevalence of carriage of antibiotic-resistant Streptococcus pneumoniae in children in Kampala Uganda. Int J Antimicrob Agents 17 : 395–400. [Google Scholar]
  14. Mermin J, Lule J, Ekwaru JP, Malamba S, Downing R, Ransom R, Kaharuza F, Culver D, Kizito F, Bunnell R, Kigozi A, Nakanjako D, Wafula W, Quick R, 2004. Effect of co-trimoxazole prophylaxis on morbidity, mortality, CD4-cell count, and viral load in HIV infection in rural Uganda. Lancet 364 : 1428–1434. [Google Scholar]
  15. Luscher D, Altwegg M, 1994. Detection of Shigellae, enteroin-vasive and enterotoxigenic Escherichia coli using the polymerase chain reaction (PCR) in patients returning from tropical countries. Mol Cell Probes 8 : 285–290. [Google Scholar]
  16. NCCLS, 1999. Performance Standards for Antimicrobial Disk and Dilution Susceptibility Tests for Bacteria Isolated from Animals. Approved standard M31-A. Wayne, PA: National Committee for Clinical Laboratory Standards, 19.
  17. Mates A, Shaffer M, 1989. Membrane filtration differentiation of E. coli from coliforms in the examination of water. J Appl Bacteriol 67 : 343–346. [Google Scholar]
  18. Wright JGS, Conroy R, 2003. Household drinking water in developing countries: a systematic review of microbiological contamination between source and point-of-use. Trop Med Int Health 9 : 106–117. [Google Scholar]
  19. Curtis V, Cairncross S, 2003. Effect of washing hands with soap on diarrhoea risk in the community: a systematic review. Lancet Infect Dis 3 : 275–281. [Google Scholar]
  20. Esrey SA, Potash JB, Roberts L, Shiff C, 1991. Effects of improved water supply and sanitation on ascariasis, diarrhoea, dracunculiasis, hookworm infection, schistosomiasis, and trachoma. Bull World Health Organ 69 : 609–621. [Google Scholar]
  21. Kirschner D, 1999. Dynamics of co-infection with M. tuberculosis and HIV-1. Theor Popul Biol 55 : 94–109. [Google Scholar]
  22. Mayanja-Kizza H, Johnson JL, Hirsch CS, Peters P, Surewicz K, Wu M, Nalugwa G, Mubiru F, Luzze H, Wajja A, Aung H, Ellner JJ, Whalen C, Toossi Z, 2001. Macrophage-activating cytokines in human immununodeficiency virus type 1-infected and -uninfected patients with pulmonary tuberculosis. J Infect Dis 183 : 1805–1809. [Google Scholar]
  23. Toossi Z, 2003. Virological and immunological impact of tuberculosis on human immunodeficiency virus type 1 disease. J Infect Dis 188 : 1146–1155. [Google Scholar]
  24. Toossi Z, Mayanja-Kizza H, Hirsch CS, Edmonds KL, Spahlinger T, Hom DL, Aung H, Mugyenyi P, Ellner JJ, Whalen CW, 2001. Impact of tuberculosis (TB) on HIV-1 activity in dually infected patients. Clin Exp Immunol 123 : 233–238. [Google Scholar]
  25. Wahl SM, Orenstein JM, 1997. Immune stimulation and HIV-1 viral replication. J Leukoc Biol 62 : 67–71. [Google Scholar]
  26. WHO, 2004. Evaluation of the Costs and Benefits of Water and Sanitation Improvements at the Global Level. Geneva: World Health Organization.
  27. Jong-wook L, 2003. Attacking AIDS and Its Ally, Hunger; World AIDS Day. The International Herald Tribune, Dec 01, 2003.

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  • Received : 27 Apr 2005
  • Accepted : 11 Jul 2005

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