People living with HIV/AIDS (PLHIV) are particularly vulnerable to and disproportionately suffer from adverse effects of inadequate water, sanitation, and hygiene (WASH), mainly due to their suppressed immune systems. Persistent diarrhea greatly reduces the effectiveness of antiretroviral therapy (ART) and other interventions. Insufficient WASH access is a serious burden that compounds the difficulty of living with HIV.

The Challenge

Worldwide, more than 34 million people are living with HIV/AIDS, 3.3 million of whom are under the age of fifteen.1 To add to the challenge, a great many PLHIV live in regions where access to WASH is limited.2, 3

Lack of WASH is linked to some of the leading causes of morbidity and mortality among PLHIV. 50 percent of PLHIV in North America and up to 100 percent of PLHIV in the developing world suffer from diarrheal disease, often caused by poor sanitation.4, 5 Not only are PLHIV at greater risk for diarrheal disease, but they generally suffer from it more frequently, have more severe episodes, and are more likely to die from it.6 A study in the Democratic Republic of Congo found that HIV positive infants are 11 times more likely to die of diarrheal disease than uninfected infants.7

Diarrheal disease is particularly dangerous for PLHIV, because it can lead to an increased viral load, thus increasing disease progression.8 In addition, PLHIV in unhygienic conditions can suffer from a condition called enteropathy, which hinders proper absorption of antiretroviral medicines and makes them less effective, in some cases leading to drug resistance.9, 10

Lastly, PLHIV need more than average amounts of water for day-to-day living. A study in Ngamiland, Botswana found that caregivers with HIV patients suffering from diarrheal disease needed an average of 20 liters more water per day to wash soiled clothes and sheets as well as sterilize contaminated areas.11


Providing access to a safe, reliable and sufficient water supply and basic sanitation is essential for both PLHIV and their caretakers. Water and sanitation services located in close proximity to HIV-affected households can have important labor saving effects, which reduce the burden of caregiving and allow more time for other activities, including school and income generation.12

In addition, research shows that increased WASH significantly reduces diarrheal episodes among PLHIV, thus enhancing their quality of life. A randomized controlled trial in Uganda using safe water systems found that PLHIV with the intervention had 25% fewer diarrhea episodes.13 The same study found that the presence of a latrine reduced diarrheal episodes by 31% and that the presence of soap reduced incidence by 42%.14 More recently, another study done in Zambia found that water filtration and safe storage among HIV positive households resulted in a 54% decrease in diarrhea.15

For more information, contact Elynn Walter, (202) 293-4048 ewalter@WASHadvocates.org

1. World Health Organization. (2014). Number of people  (all ages) living with HIV. http://www.who.int/gho/hiv/epidemic_status/cases_all_text/en/

2. Tebit, D. M., & Arts, E. J. (2011). Tracking a century of global expansion and evolution of HIV to drive understanding and to combat disease. The Lancet infectious diseases, 11(1), 45-56.


3. Hutton, G., & Bartram, J. (2008). Regional and global costs of attaining the water supply and sanitation target (Target 10) of the Millennium Development Goals. World Health Organisation, Geneva.


4. Smith, P., Colebunders, R. & Mayer, H. as cited in Monkemuller, K.E. & Wilcox, C.M. (2000). Investigation of Diarrhea in AIDS. Canadian Journal of Gastroenterology 14(11), 933-40.

5. Momba, M. N. B., Madoroba, E., & Obi, C. L. (2010). Apparent impact of enteric pathogens in drinking water and implications for the relentless saga of HIV/AIDS in South Africa. Current Research, Technology and Education Topic in Applied Microbiology and Microbial Biotechnology. Formatex Microbiological Series. (2), 615-625. http://www.formatex.info/microbiology2/615-625.pdf

6. Stark, D., et. al. (2009). Clinical Significance of Enteric Protozoa in the Immunosuppressed Human Population. Clinical Microbiology Review. 22 (4) 634-650.

7. Thea, D, et al. (1993). A prospective study of diarrhea and HIV-1 infection among 429 Zairian infants. New England Journal of Medicine. 329(23), 1696-7.

8. Brink, A., et al. (2002). Diarrhea, CD4 counts and enteric infections in a community-based cohort of HIV-infected adults in Uganda. Journal of Infection. 45(2), 99-106.

9. Prendergast, A. & Kelly, P. (2012). Enteropathies in the Developing World: Neglected Effects on Global Health. American Journal of Tropical Medicine and Hygiene. 86(5), 756-763.

10. Bushen, O., et al. (2004). Diarrhea and Reduced Levels of Antiretroviral Drugs: Improvement with Glutamine or Alanyl-Glutamine in a Randomized Controlled Trial in Northeast Brazil. Clinical Infectious Diseases. 38(12), 1764-70.

11. Ngwenya, B. & Kgathi, D. (2006). Access to Water and HIV/AIDS: A Case Study of Home Based Care in Ngamiland. Physics and Chemistry of the Earth. 31(15-16), 669-680. http://www.ubrisa.ub.bw/handle/10311/172.

12. Catholic Relief Services. Innovations in Water and Sanitation. http://www.crsprogramquality.org/storage/pubs/watsan/WatSan-innovations-PLHIV2.pdf.

13. Lule, J., et. al. (2005). Effect of home-based water chlorination and safe storage on diarrhea among persons with human immunodeficiency virus in Uganda. American Journal of Tropical Medicine and Hygiene. 73(5), 926-33.

14. Ibid.

15. Peletz, R., et al. (2012). Assessing Water Filtration and Safe Storage in Households with Young Children of HIV-Positive Mothers: A Randomized, Controlled Trial in Zambia. PLoS ONE. 7(10), e46548. http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0046548.

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