It's the Water

In Addition to Drinking Enough, People with HIV/AIDS Need to Consider Water Safety

Water is the most abundant component of the human body, making up about 60 percent of the total body weight in an adult.

Your body is unable to store water. Therefore, staying hydrated by drinking water throughout the day is important.

If you feel thirsty, you may already be under-hydrated. To avoid thirst, drink water or other caffeine-free fluids throughout the day.

Are You Drinking Enough Water?

Drinking adequate amounts of water may help ease a headache or decrease fatigue. Eating food can do the same if you have not eaten recently.

Under normal situations, the recommended fluid intake is nine to 11 cups for women and 10 to 12 cups for men. (8 ounces = 1 cup.)

If you are experiencing diarrhea and are exercising or participating in cold or hot weather activities, you need to drink more water than usual. Sports drinks, diluted juices, or oral rehydration beverages (Pedialyte, Ceralyte, Infalyte) are important to drink when having diarrhea. If diarrhea persists for more than a few days, consult your physician.

Approximate Daily Loss of Water (in Cups)
 Normal Temperature
Hot Weather
Prolonged Exercise
Insensible Loss:
Respiratory Tract




Take Precautions

In addition to drinking enough, people with HIV/AIDS need to consider water safety.

Is tap water safe? What about swimming pools and hot tubs? Are they safe? Do you need to boil tap water to make it safe to drink?

The Centers for Disease Control and Prevention (CDC) strongly states that you should not drink water directly from lakes, rivers, streams or springs. Those who want to take extra precautions may wish to boil tap water or drinking water that has been processed in such a way as to eliminate parasites such as Cyptosporidium or giardia for those with compromised immune function. These precautions are particularly important if you are traveling outside of the U.S., since water standards elsewhere may be different.

Boiling water may be the most reliable method to make water of uncertain purity safe. The recommendation is to bring water to a rolling boil for at least one minute, or at least three minutes where the altitude is greater than 6,500 feet. Cool the water to room temperature and put into clean containers with lids and store in the refrigerator.

Water that has been adequately chlorinated provides significant protection against viral and bacterial waterborne diseases in the United States. However, chlorine treatment alone may not kill some enteric viruses or the parasites that cause cryptosporidiosis, giardiasis and amebiasis.

Is Los Angeles Tap Water Safe?

According to the Los Angeles Department of Health Services (DHS) Acute Communicable Disease Control, there is no reason to be concerned with transmission of giardiasis or cryptosporidiosis through municipal water supplies of Los Angeles City Department of Water and Power (DWP).

DHS says that no evidence for transmission through municipal water supplies has been found at all.

In Los Angeles, DHS and the health officer have the legal authority to issue public notices regarding water and food contamination. No declarations to boil water have been issued since the Northridge earthquake in 1994. Barring any natural disaster or incidents, drinking Los Angeles tap water is believed to be safe.

The reported number of cases of cryptosporidiosis and giardiasis reported to the Public Health Department dropped three years ago, and the LADWP has maintained enhanced laboratory surveillance for these diseases since 1995.

In 1998, 670 cases of giardia were reported (annual incidence of 7.37 cases per 100,000), the lowest rate ever for L.A. County. In 1998, 93 cases of cryptosporidiosis were reported (annual incidence of 1.02 cases per 100,000). The incidence was greatest in middle-aged adults between the ages of 35 and 54.

At least half of the cases were HIV-associated. Person-to-person transmission seems to be by far the most common source of cryptosporidiosis among persons living with HIV.

To Drink or Not to Drink

Everyone has to make up his or her own mind about whether to drink tap water, and do what feels most comfortable.

Given what DHS says, hopefully people with HIV can be less anxious if they choose to drink local tap water when nothing else is available. For many, bottled water is preferred as a matter of taste.

Purchasing water from store vending machines may be risky. The cleanliness of the machine and the maintenance of its filters may be in question. CDC says there are no guidelines in place regarding vending machines. Consider boiling your water or buying bottled water if you choose not to drink tap water.

Other Diseases from Pools

Although the extent to which water in swimming pools, spa pools and hot tubs is a threat to public health is difficult to define, its association to illness is recognized.

Maintaining adequate levels of chlorine can inactivate or control most pathogens in swimming pool water. In spa pools, elevated water temperature, turbulent water, and heavy bather load lead to the rapid depletion of disinfectants, and higher levels of disinfectant may be needed.

Pseudomana aeruginosa is the most frequently isolated organism in spa pools. It is most often responsible for outbreaks of folliculitis (inflammation of hair follicles) and skin dermatitis, but can also cause otitis (ear infection), pneumonia and urinary tract infections. Exposure time to the contaminated water is an important factor in determining whether a person will become ill.

Fecal Accidents

Fecal accidents (release of stool into the water) occur frequently at public pools, and can cause illness.

As few as 10 cryptosporidium oocysts (the egg of the parasite that has a hard capsule and carries the parasite from host to host) can cause illness. In 1988, an outbreak in Los Angeles County involved 60 cases of cryptosporidiosis in persons swimming in a 100,000-gallon swimming pool in which there was a single fecal accident. Length of exposure and immersing the head under water were risk factors in contracting the disease.

Other outbreaks in Oregon, Wisconsin, British Columbia and Great Britain have been reported.

The amount of chlorine needed to rapidly deactivate cryptosporidium oocysts cannot be maintained while bathers are using the pool. Currently, there are no precise guidelines from CDC stating how long the facility should be closed when there is a fecal accident, but only that it should be closed.

This presents a problem for health officials who might want to close down a water park for the day or part of the day when such an occurrence happens; the owners are saying, "show me where it's written that you need to close it for the day."

The U.S. Public Health Service recommends that people with weakened immune systems or CD4 counts below 200 should not swim in recreational waters (such as oceans, pools or lakes). If they choose to do so, they should avoid swallowing water or immersing their head.

Elevated bacteria levels in ocean waters resulting from heavy rains can also cause illness. When a rain advisory is in effect, the DHS recommends that beach-goers avoid contact with ocean water, particularly near storm drains, for 72 hours after rainfall ends.

A sewage or chemical spill may cause a beach to be closed down. Avoid all contact with ocean water where closure signs are posted.

The Los Angeles County Environmental Health Ocean Water Monitoring Program provides rain advisory and beach closure information. The DHS website is:

Factors that increase risk of contamination from bacteria in recreational water include:

  • Sharing pool water with children wearing diapers or not toilet trained.

  • Using small pools where the dilution factor is smaller than in larger pools. An Olympic-size pool usually holds 100,000 gallons of water, whereas an apartment, hotel, or health club pool may contain only 10,000 to 15,000 gallons, and spa pools or hot tubs only 1,000 gallons.

  • Heavy bather use. For example, pools may be very crowded on weekends, and this can dilute chlorine levels and overburden pool filtration systems.

  • Putting your head under water or swallowing water.

  • Spending a lot of time in the water.

What About When I Travel?

Taking extra precautions to avoid illness from water is especially important while traveling.

Drinking bottled or canned beverages is much safer than using local water supplies. When dining at a restaurant, ask for an unopened bottle of water instead of water poured from the tap or a pitcher. Wipe off any condensation or moisture from the bottle or can. Avoid ice cubes unless you know they have been made with safe water.

CDC says coffee and tea that have been made with water reaching at least 175 degrees F will be safe. This may not include iced teas or coffees you purchase. Brush your teeth with bottled water or water that has been boiled.

Bottled Water and Filters

Selling bottled water is a big business and the market for bottled water is worldwide.

Too frequently, the method of treatment is not identified on the bottle or container. When in doubt, call the number for the manufacturer, often found on the product's container, and ask. If manufacturers get enough calls, they may decide to make this information available on their product's label.

When shopping for a filter, look for the words "NSF Certified," and then the words "for the removal of cryptosporidium."

If you have any questions about whether the filtration system you are considering buying removes cryptosporidium or other parasites, call NSF at (800) NSF-MARK (800-673-6275) or (800) 673-8010. Tell them the exact model number and brand name you are considering.

Information can also be retrieved from the NSF website at

AIDS Project Los Angeles' HIV and Nutrition Program offers materials to assist individuals comparing bottled water or filters. Stop by APLA's HIV Resource Center and pick up the flier on NSF called "Clear Facts!" with a partial list of some bottled waters and how the water is treated.

Bottled Water and Fluoride

The low fluoride content of most bottled water is a concern to many members of the dental profession. The use of fluoridated water is a major factor in the prevention of tooth decay in children and adults. If you drink only bottled water, brushing your teeth with a toothpaste that contains fluoride is recommended.

Contact your dentist if you have any concerns about fluoride.

Janelle L'Heureux, M.S., R.D., is a registered dietitian in APLA's Client Health Education and Advocacy program. She can be reached at (323) 993-1556 or by e-mail at

This article has been reprinted at The Body with the permission of AIDS Project Los Angeles (APLA).