Dr, I have had the trots for years now! HIV manifested in my gut in 2001 and that has been my biggest problem ever since.

I take 2 x Aluvia(as new Kaletra is known in South Africa) and 1 x Combivir twice a day. I have been on this regimen since the old 3 x Kaletra twice a day got replaced by the new formula(Aluvia) and before that I was on Kaletra / Combivir.

My CD4 count is 384 and viral load has been undetectable for 3 years. I am healthy and my last respiratory tract infection was 2 months ago and I beat that with over the counter meds and vitamins. Several HIV neg friends and colleagues were in fact bedridden and needed anti-biotics that same week.

I have been on various anti-diarrheal medications over the years and nothing has a lasting effect. I have taken psyllium husks, and a variety of potions and herbal concoctions. I have eaten yogurt by the bucket full and changed my diet at times to exclude almost everything hearty and appetizing. Initial positive effects of the no-fun-eating-plan quickly dissipate and the only lasting effect is me having disturbing dreams of juicy steaks and lasagna.

In November 2008 I had a colonoscopy and a gastroscopy and the results were an all clear. 3 Months ago my GP gave me a script for codeine phosphate of which constipation is a side-effect. Life was wonderful. No more diarrhea. I thought I had died and gone to heaven - no cramping, no rushing home to get to the loo, no stress. I started doing my bit to save the rain forests by using vastly reduced amounts of ultra soft double ply toilet paper.

Then came the bummer. As with every other thing I have tried over the years codeine phosphate stopped being effective. Diarrhea is back with a vengeance! I run up to 5 times a day and when I've got to go I've got to go!

I drop business calls to run to the bog. I sit in the traffic and play mental games and chew my knuckles praying that I will make it home/to the office/closest acceptable public convenience before the floodgates open and I end up in shit street(literally).

My GP says he has no more answers and has referred me to the top HIV specialist in town. Unfortunately I just cannot afford the rates this Medicine-god charges and he is not at all negotiable.

So Dr, please help. What can I do (that I have not tried before) to stop or at least just slightly alleviate the constant diarrhea that prevents me from leading a normal life?

H in Johannesburg

If any alternative protease inhibitors are available to you (such as atazanavir or darunavir) they often have a lower rate of loose stools then with lopinavir. Also a switch from Combivir to Truvada or Epzicom (if HLA B5701 negative)might help some patients depending on pasat treatment history and resistance situation. Some patients have a loose stool benefit from calcium supplements. I assume you have been evalauted for lactose or gluten intolerance. KH