It Takes Guts: Probiotics and Other Strategies for Digestive Health and HIV
From the moment you pop them into your mouth till they come out the other end, food and beverages take a long, fascinating ride through a tube within you called the gastrointestinal (GI) tract. As we continue to learn more about the reality that you indeed are what you eat (and drink), what should people with HIV know about the supplements or other approaches to digestive health that can help this journey go well?
The gut is a prime site for HIV to hang out in -- primarily because that's where a significant percentage of the T cells (also known as CD4+ T lymphocytes, or CD4 cells) hang out, many of them activated. HIV is known to severely deplete T-cell numbers in the gut.
Opportunistic infections can appear, particularly when someone is not on antiretroviral treatment, such as candidiasis (due to yeast), CMV infection, KS, MAI infection and cryptosporidiosis. Happily, we are not seeing these infections nearly as often, but parasites can still be a problem. That's why anytime diarrhea doesn't resolve on its own, careful testing should be done to determine a possible cause and treat that appropriately.
Antiretroviral treatment itself -- particularly, but not exclusively, protease inhibitors -- can also cause GI troubles. And even when HIV is suppressed below the limit of detection, we are understanding more and more that inflammation plays a major role in ongoing damage to the GI tract. Clinically, people can suffer diarrhea, bloating and gas as manifestations. But fortunately, there are numerous ways to address these issues that go beyond just reaching for an antacid or a proton-pump inhibitor!
So, let's take that journey down the GI tract, and talk about what can make for a smoother ride. Your nourishment (one hopes it is nourishing!) starts to be digested the moment it's in your mouth being chewed and processed by enzymes in your saliva. Then it heads down the esophagus and into the highly acidic stomach, where digestion begins in earnest. From there, it goes into the duodenum where it faces bile from the gall bladder (produced in the liver) and enzymes (produced by the pancreas). Then it's on to the small intestine where nutrients are extracted and then the material is passed on into the large intestine. And then voila: shit!
Of course, we mustn't neglect the absorption of fluids. These pass through the kidneys and are excreted as urine -- all the more reason to keep an eye on bloodwork that assesses the function of the kidneys, especially for people of African descent and anyone using medications like tenofovir (found in Viread, Truvada and Atripla).
At the top of your list for managing GI journeys should be your diet, exercise and sleep. All of these can play roles in digestion and absorption.
For example, try not eating right before sleep and address issues, like sleep apnea, that can take the restfulness out of a night's sleep. Avoid all soft drinks, plus processed foods and junk foods. Work to find a diet that is pleasurable and full of the right balance of vegetables, fruits and grains (one example here gives general ideas from the world of coping with inflammatory bowel syndrome [IBS]).
While the gluten-free fad may be overdone at this point, data show that many do have a sensitivity to gluten -- so it may be worth a try. Designing a diet that fits your body type has to be holistic and patient-centered, but taking control over what we put in our face is one of the first and best places to be empowered.
Prebiotics and probiotics (or combinations known as synbiotics) are well worth contemplating. We are beginning to understand more about the enormous array of "friendly" bacteria and fungi (and even some viruses) found in and on the human body known collectively as the human microbiome. These organisms are diverse and interactive, forming ecologies that are different at various sites. So what happens in the mouth is distinct from the small and large intestine and from the vagina or rectum. The skin, eyes and other sites all have their own ecologies of critters, estimated to collectively represent a great deal more DNA from non-you sources than our own cellular DNA in their sheer weight!
There are some mixed data on the use of probiotics in the context of HIV. Diarrhea may be best dealt with using a yeast extract known as Saccharomyces boulardii, for which there are some robust data. Which probiotics are best for managing diarrhea is not yet clear and the data are somewhat mixed. Children with HIV seem to do the best. There is some data suggesting that a mix of probiotics may help modestly improve CD4 percentage among adults.
Species of probiotic bacteria like Lactobacilli are not only important for the gut, but also for a healthy vagina. Using probiotics may help to reduce the recurrence of bacterial vaginosis as well as the duration of antibiotic therapy to treat it. (As an aside, stunningly, there are no studies of interventions among HIV-positive women to treat vulvovaginal candidiasis.)
Glutamine, an amino acid that acts as a fuel for the turnover of the lining of the gut, has been studied in the context of diarrhea associated with the use of protease inhibitors. Along with probiotics, high doses of glutamine for a short time can help offset this substantially.
Another issue for people with HIV often is that there is actually less acid in the stomach than needed to digest food, a condition called hypochlorhydria. There are some methods to test for this and you can ask your physician. One supplement that may be tried -- with care since you don't want to increase acid content if you have enough already -- is betaine hydrochloride. This can help improve stomach acidity.
Taking enzymes as supplements may help your body further break down foods into their more absorbable components. Such supplements can include enzymes that break down sugars (such enzymes are called amylases), proteins (proteases) and fats (lipases) and may be derived from animal or vegetarian sources. This might be an approach to try on its own for a month to see if it helps to improve your symptoms.
At the New York Buyers' Club (NYBC), we have also used traditional remedies, including mixtures of Chinese herbs, to help soothe inflamed guts. Two combinations include GastroSoothe and Quiet Digestion. Each comes from a company we have worked with for years and whose quality we trust. Could we get clinical trials of these kinds of interventions? Sadly, it's not likely. Instead, we've seen the vast majority of public funding going into trials for patented pharmaceutical agents such as proton-pump inhibitors, which have a serious risk of damaging gut function and potentially increasing the risk of infection by C. difficile.
So, while we have some good data to support many of these interventions, we still have to fly by the seat of our pants a bit. For people with HIV looking for answers to GI troubles, it's important to try things in a way that gives you the best shot at assessing whether they are of benefit to you, in order to help improve your overall quality of life to accompany the increased quantity of life antiretroviral drugs are providing for so many.
George M. Carter is the administrator for the New York Buyers' Club (NYBC) and founder/director of the Foundation for Integrative AIDS Research (FIAR). He has been undertaking systematic reviews and meta-analyses of various questions around integrative medicine and HIV with a team at the Mount Sinai School of Medicine.