Worldwide, 748 million people do not have access to improved drinking water sources and 2.5 billion people are without improved sanitation.1 Each year, 61 million disability-adjusted life-years (DALYs) are lost because of the estimated 4 billion cases of diarrhea caused by unsafe drinking water and sanitation.2,3 The Millennium Development Goals for water and sanitation are to reduce by half the proportion of the population without access to “improved” water sources (such as protected wells or piped water supplies) and sanitation facilities (such as ventilated improved pit latrines and sewerage). Access to improved water supply and sanitation facilities are particularly poor in low-income and middle-income countries (LMICs). In several LMICs formerly considered US President's Emergency Plan for AIDS Relief (PEPFAR) focus countries, only 40% (6 of 15 countries) met the safe drinking water goal and 7% (1 of 15 countries) met the sanitation goal in 2012, according to the World Health Organization (WHO) and UNICEF Joint Monitoring Report (Table 1).4,5 Furthermore, a substantial proportion of improved water supplies are not considered safe, more than doubling the population at risk.6,7
Persons living with HIV/AIDS (PLHIV) are at an increased risk of enteric infections from waterborne pathogens that cause diarrhea,3,8–10 and experience more severe diarrhea, hospitalizations, and diarrheal-related deaths compared with immunocompetent populations.11,12 These risks persist even for patients on antiretroviral therapy (ART).13–15
Waterborne pathogens can be bacterial, viral, or parasitic and include Vibrio cholerae (cholera), pathogenic Escherichia coli, Cryptosporidium parvum, Giardia lamblia, Salmonella Typhi (typhoid fever), Shigella, and helminths. Water, sanitation, and hygiene (WASH) interventions—such as installing a protected well (water supply), distributing chlorine tablets (water quality), latrine construction (sanitation), or hand-washing promotion (hygiene)—aim to break the fecal-oral transmission route and provide a foundation for health, nutrition, a safe living environment, and improved quality of life. WASH programming that targets PLHIV also benefits their families and communities by reducing exposure to, and transmission of, disease-causing organisms.
The 2 most common indicators for assessing the impact of WASH interventions are diarrhea rates and prevalence of waterborne pathogens among people presenting with diarrhea. The WHO defines a case of diarrhea as “3 or more loose watery stools in a 24-hour period”; this indicator is evaluated by self-reported recall of the beneficiary/patient or through a review of clinical records. For programs targeting PLHIV, diarrhea cases are reported for PLHIV and sometimes also for family members (eg, diarrhea for children <2 with an HIV+ mother). The prevalence of waterborne pathogens is evaluated through stool samples that are collected and analyzed, which is costly, time-consuming, and requires laboratory equipment and trained personnel. Both indicators are usually expressed using a relative ratio of risk or exposure [ie, risk ratio (RR), odds ratio (OR), or hazard ratio (HR)].
The WHO guidance from “Essential Prevention and Care Interventions for Adults and Adolescents Living with HIV in Resource-limited Settings” (2008) states that simple, accessible, and affordable WASH interventions have been effective in reducing the risk of diarrheal diseases.16 Household water treatment, sanitation, and personal hygiene interventions have been found to be cost-beneficial and (for patients on ART) reduce the risk of contracting diarrheal diseases that reduce drug absorption.17
The objective of this review was to examine the existing literature on the impact of WASH interventions on PLHIV, including water supply, water treatment, sanitation, and hygiene. WASH strategies and conclusions that are widely applicable regionally or globally were of particular interest. In this review, we assess the quality of published studies and describe the impact of WASH interventions on the following outcomes: (1) mortality, (2) morbidity, (3) retention in HIV care, (4) quality of life, and (5) prevention of ongoing HIV transmission. Cost-effectiveness of WASH interventions was also assessed.
A literature review was conducted by accessing 6 databases: (1) African Index Medicus, (2) CINAHL, (3) Embase, (4) Global Health, (5) Medline, and (6) Sociological Abstract. Articles from January 1995 to June 2014 were reviewed for (1) PLHIV (adult and adolescent populations); (2) focused or applied to resource-limited countries; (3) focused on 1 or more outcomes of interest (mortality, morbidity, retention in HIV care, quality of life, prevention of ongoing HIV transmission); and (4) related to WASH program objectives and interventions designed to reduce the risk of diarrhea or prevalence of waterborne pathogens. The key terms that are uniquely relevant to the WASH review search strategy are presented in Table 2.
After all relevant abstracts were gathered and duplicates were eliminated, an initial screening was carried out to focus the wide variety of searches to WASH and PLHIV. This systematic screening of the abstracts eliminated those not specific to WASH or PLHIV, including (1) small clinical trials limited to the laboratory or hospital that did not approach WASH as a programmatic initiative; (2) articles focused only on the prevalence of waterborne diseases without a connection to WASH programming; and (3) studies focused on male and female circumcision, douching, breastfeeding, and nutrition (unless a direct connection to WASH programming was established). Abstracts that passed the initial screening were reviewed independently by the research team and collaboratively discussed to determine whether to include full article review. Articles that met the selection criteria were reviewed by all team members and sorted by thematic outcomes of interest. The strength of association between WASH and PLHIV was also specifically considered. Consensus was required among the researchers for inclusion of articles in the review.
For each included article, the overall quality of evidence was rated as “strong,” “medium,” or “weak” considering quality of the study design, cohort population, and sample size. Impact was assessed through key outcomes considering the magnitude of effect (eg, RRs, HRs) on the target population. This approach allowed the research team to assess the internal/external validity and the application for broader contexts. For each outcome of interest, the overall quality of evidence in the articles that addressed the outcome was rated as “good,” “fair,” or “poor”; the expected impact, based on existing published evidence, of WASH programming on that outcome was rated as “high,” “moderate,” “low,” or “uncertain.” Cost-effectiveness was separately but similarly assessed by a health economist at the Centers for Disease Control and Prevention. More details of the assessment are described in the Introduction to this supplement, found on page S253.
For this literature review, we screened 3355 citations, closely read 132 abstracts, evaluated 33 articles, and included 16 articles in the final review (Fig. 1). The majority of the evaluated articles focused on morbidity (16), with a lesser emphasis on mortality (2). Two articles were included in both morbidity and mortality outcomes. Within the morbidity and mortality outcomes, cost-effectiveness was evaluated in 3 articles. No article addressed the relationship between WASH and the other 3 outcomes (retention in HIV care, quality of life outcomes, or HIV transmission). The methods, study populations, and key findings of the 16 articles meeting the final inclusion criteria are summarized in Table 3.
One study with mortality as an outcome met the evaluation criteria. A prospective cohort study in Kenya evaluating long-lasting bed nets (LLBNs) and household water filters did not find a difference in mortality between intervention and control groups over a 2-year period (1.5 compared with 1.4 deaths per 100 person-years, respectively).19
The overall quality of evidence of studies examining mortality was determined to be “poor,” with “uncertain” impact because of the limited number of studies and inconclusive results.
The results relating to morbidity included all major aspects of WASH programming: (1) household water treatment and safe storage (HWTS); (2) water supply; (3) sanitation (including the local environment); and (4) hand-washing. The effect on morbidity was most often described through diarrhea rates or prevalence of waterborne disease-causing agents.
Household Water Treatment and Safe Storage
The impact of HWTS on PLHIV has been widely studied. Peletz et al conducted a meta-analysis evaluating the health impact of HWTS options on PLHIV. The meta-analysis included 7 studies evaluating 4 different HWTS interventions (including chlorination, hollow-fiber filters, ceramic filters, and filters plus UV radiation), diarrhea was reduced in PLHIV or their family members by 43% [pooled RR = 0.57; 95% confidence interval (CI): 0.38 to 0.86].24 Several of the studies in Peletz et al are also detailed in this analysis, alongside additional studies.
In an RCT, distribution of sodium hypochlorite solution and safe storage in Uganda led to 25% fewer episodes of diarrhea [Adjusted Incidence Rate Ratio (IRR) = 0.75; 95% CI: 0.59 to 0.94; P = 0.015] and an even greater diarrheal reduction of 67% among PLHIV when sodium hypochlorite was used in conjunction with cotrimoxazole prophylaxis (IRR = 0.33; 95% CI: 0.24 to 0.46; P < 0.001).11 Additionally, there was also a 44% reduction in viral load for PLHIV in the intervention group compared with the control group (0.71 log10 to 0.4 log10 per person-year: adjusted mean pairwise difference = −0.14 log10 per person-year; 95% CI: −0.55 to 0.27; P = 0.510).11 In a prospective cohort study in Nigeria, PLHIV using sodium hypochlorite solution with a safe storage container had 36% fewer diarrhea episodes (P = 0.04); frequent chlorinators were 3 times less likely to report diarrhea than infrequent chlorinators (15% compared with 46%).21
In a prospective cohort study, PLHIV in Kenya given a hollow-fiber household water filter and an LLBN were found to have a slower CD4 decline (P = 0.03), did not fall below the <350 cells per cubic millimeter threshold as often (HR = 0.73; 95% CI: 0.57 to 0.95); and reported less diarrhea (RR = 0.65; 95% CI: 0.45 to 0.93).19 In further analysis from the same study, filter provision reduced diarrhea by 61% (OR = 0.39; 95% CI: 0.23 to 0.66; P < 0.001) and was effective when filter users were also taking cotrimoxazole prophylaxis (OR = 0.47; 95% CI: 0.25 to 0.88; P = 0.02).14
In an RCT with an ART-targeted population in South Africa, PLHIV households using a silver-impregnated ceramic water filter had a 25% lower prevalence of Cryptosporidium (P = 0.02) and 79% lower diarrhea rates than the control group [Adjusted Odds Ratio (AOR) = 0.21; 95% CI: 0.18 to 0.26; P = 0.0001].15 In a cross-sectional study in Kenya, consumption of boiled or household-treated water was associated with less severe diarrhea than those using untreated water (AOR = 0.23; 95% CI: 0.13 to 0.83).27
Access to improved water sources was associated with a lower prevalence of intestinal parasites (IPs) and diarrhea among PLHIV and their household members. In a cross-sectional study among PLHIV in Kenya, piped water, treated water, and a reliable water source were protective against IPs (P = 0.0001; 0.0001; and 0.04, respectively).26 In a cross-sectional study in Cameroon, the use of protected water sources was associated with reduced IP prevalence among PLHIV (AOR = 2.4; 95% CI: 1.2 to 5.2).10 Conversely, an increased risk of IPs for households without access to improved water sources was found in separate cross-sectional studies in Ethiopia (AOR = 6.03; 95% CI: 1.1 to 32.0)22 and Zimbabwe (RR = 1.9; 95% CI: 1.1 to 3.1).25 In another cross-sectional study in Ethiopia, PLHIV using unimproved sources were more likely to have diarrhea than those using protected sources (AOR = 6.1; 95% CI: 1.2 to 30.6).23
In a cross-sectional study in Ethiopia, access to a sanitation facility (eg, latrine) reduced the risk of IPs in PLHIV (controlling for ART, AOR = 7.57; 95% CI: 1.3 to 44.2).22 In a case–control study in India, the prevalence of IPs among individuals practicing open defecation (12%) and relying on public toilets (47%) was significantly greater than household toilet users (7%; P < 0.01).28 Lack of household latrine availability was a significant risk factor for diarrhea in a cross-sectional study from Ethiopia (AOR = 10.39; 95% CI: 5.13 to 21.03; P < 0.05)23 and in an RCT in Uganda (IRR = 0.69; 95% CI: 0.53 to 0.91; P = 0.009).11
In a cross-sectional study in Kenya, contact with cows (OR = 3.2; 95% CI: 1.26 to 8.13) and pigs (OR = 11.2; 95% CI: 3.8 to 43.6) were significant risk factors for diarrhea in PLHIV.27 Exposure to animal dung was a significant risk factor for IPs in PLHIV in cross-sectional studies from Zimbabwe (RR = 2.2; 95% CI: 1.6 to 2.9)25 and Ethiopia (Crude Odds Ratio [COR] = 3.56; 95% CI: 1.3 to 9.9).22 In a case–control study in India, pets and animals were also significantly associated with IP prevalence in PLHIV (P < 0.05).28
In an RCT in Uganda, the presence of soap in the home corresponded with a reduction in days ill with diarrhea among PLHIV (IRR = 0.58; 95% CI: 0.35 to 0.97; P = 0.038).11 In an RCT, active and targeted hand-washing promotion for PLHIV in the United States decreased diarrheal incidence from 2.9 to 1.2 episodes per year (P < 0.001) with a marked increase in the frequency of hand-washing from 4 to 7 times per day; this was outside the scope of this research because it is based in the United States but remains applicable to resource-limited countries.31
The overall quality of evidence of studies examining the impact of WASH programming on morbidity was determined to be “good,” with “high” expected impact.
WASH programs are cost-effective in many development contexts32; this review found that this remains true for WASH interventions targeting PLHIV. Related studies with water filters and LLBN for PLHIV delayed the entry of HIV+ individuals into ART by slowing the rate of decrease of CD4 counts in Kenya.20,33 The program resulted in significant benefits compared with costs; the costs per DALY averted were less than US $20 in 93% of simulations in 1 study30 and US $99 in another.20 However, outcomes were not presented separately for water filters and LLBN in either study. In an HWTS program in Uganda using sodium hypochlorite solution and improved storage, the cost per diarrhea episode averted was US $5.21 but the cost per DALY averted was US $1252, above standard thresholds for cost-effective interventions in low-income countries, such as 3 times GDP per capita (reported by the World Bank as US $236 for Uganda in 2002).29 Because this program involved intensive treatment of ill persons and was not designed to detect mortality, the authors conducted a sensitivity analysis incorporating mortality data from a trial of a similar HWTS intervention in the region, which reduced the estimated cost to US $11 per DALY averted.34 Results of these studies suggest that WASH interventions for PLHIV are cost-effective because they slow HIV progression and avert the cost of diarrhea treatment. The overall quality of evidence of studies examining the cost-effectiveness of WASH programming was determined to be “good,” because the cost per DALY averted was favorable and within the accepted threshold of cost-effectiveness for most studies.
We identified 16 peer-reviewed articles focused on WASH interventions for PLHIV adults in resource-limited countries. Articles spanned 15 years (1999–2014) and represented 8 countries, including countries in East, West, and Southern Africa, as well as India. For the 5 outcomes of interest in this systematic review, we conclude that WASH programming reduced morbidity, was inconclusive for mortality, and did not address retention in HIV care, quality of life outcomes, or HIV transmission. Compared with the standard threshold of 3 times GDP per capita, some WASH interventions were found to be cost-effective, particularly when incorporated into complementary programs. General conclusions for each thematic outcome of interest are summarized in Table 4.
The articles we reviewed had several important methodological limitations. Many evaluations used self-reported diarrhea rates as the outcome, which is subject to survey bias. Several studies were funded by water treatment product manufacturers, which raised the possibility of conflict of interest. It can be difficult to compare results from studies that included all members of HIV-infected households instead of only PLHIV. Lastly, researching WASH interventions alongside other disease prevention measures (such as LLBN or the use of cotrimoxazole) without a study design that allows researchers to separate the impacts leads to unclear results.
Although the spectrum of WASH interventions is broad, the majority of the research effort has been focused on water supply and water treatment. Research has shown that improved sanitation and hygiene education are effective, sustainable, and cost-efficient ways to reduce diarrhea, but they are often overlooked.32,34,35 Our review of WASH interventions related to PLHIV also focused on water, as all 16 reviewed articles evaluated water supply, water treatment, or general risk factors. Sanitation and hygiene were often only secondary results in these articles. Additional research is required on the impact of improved sanitation and hygiene on the health of PLHIV and on the value of approaching WASH holistically.
The use of ART for PLHIV, regardless of CD4 count, is now widespread. However, research targeting the incremental benefit from WASH interventions with ART is lacking. Only 1 study targeted PLHIV on ART,15 and 2 other studies combined cotrimoxazole prophylaxis with WASH.11,14 The results of these studies had incremental, yet significant, impacts from WASH interventions targeted to PLHIV on ART or cotrimoxazole prophylaxis.
Only 2 of the 5 reviewed thematic outcomes of interest (morbidity and mortality) were specifically addressed in the literature that met criteria for inclusion in this review. The majority of the selected articles and the body of research were dedicated to 1 outcome (morbidity), and the research methodology quality varied widely. Three other thematic outcomes of interest (retention in care, quality of life, and HIV transmission) are beyond the traditional scope of WASH programming and evaluation. As an example, a theoretical cost analysis was conducted to evaluate prevention of female genital lesions because of schistosomiasis, which could potentially reduce the risk of HIV transmission; however, the article did not meet the inclusion criteria for the review because there was no program implementation.36 Behavior change research on community-based WASH interventions could specifically address these less-traditional WASH outcomes. Additional research is also needed for mortality.
Specific scenarios are unique, and no WASH intervention has been shown to be a “silver bullet” applicable in all circumstances.37 For example, chlorine is an effective water treatment strategy in many scenarios but is not effective at inactivating C. parvum.38 Progress has been made to incorporate WASH into the multifaceted needs of PLHIV, although conflicting PLHIV program priorities remain barriers.39 Further research is needed to examine the wider societal impact of WASH interventions and the nexus of WASH with health and nutrition.
Programmatic Considerations for Implementation
Contaminated water, lack of sanitation, and poor hygienic practices in homes of PLHIV increase the risk of diarrhea, which can result in increased viral load, decreased CD4 counts, and reduced absorption of nutrients and ARVs.11,40 Programs can mitigate or eliminate these effects by ensuring access to safe drinking water, sanitation, and hygiene through measures including (1) installation of improved water sources or piped water into the home; (2) distribution of HWTS options such as water filters or chlorine; (3) proper disposal of human feces in an improved sanitation facility and isolation from animal feces; and (4) distribution of soap and promotion of hand-washing with soap after defecation, handling of human or animal feces, and before food preparation and eating. Targeting the entire household, not only PLHIV, reduces exposure risk for PLHIV living within the household and for the rest of the community. In addition, although stigma and discrimination toward PLHIV have been identified as barriers to individuals accessing WASH interventions,23,41–44 community-based and social marketing interventions that address this barrier have been effective and should be considered.21,45
WASH interventions can also be integrated into community structures such as health facilities46,47 and schools.48,49 In health facilities that treat PLHIV, patients and staff should have access to safe drinking water, adequate sanitation, and hand-washing facilities with soap to reduce the risk of health facility–acquired infections. Providing water treatment products or soap can also serve as an incentive for patients to increase the use of health services and improve health outcomes.11,46,50,51
The scope of this review did not include children or infants living with HIV/AIDS. However, because WASH is critical to prevent childhood deaths from diarrhea, some discussion on the research on WASH and children and infants living with HIV is warranted. Safe water is necessary to protect the health of infants during formula feeding or early weaning from HIV-infected mothers.16 Water access within the compound, as compared with at public sources, significantly reduced the risk of death in HIV+ children in Tanzania (adjusted hazard ratio, 2.92; 95% CI: 1.03 to 8.30; P < 0.04).12 Parental hand-washing practices and the presence of soap in the house were protective against diarrhea in HIV+ children in Botswana and Zambia (AOR = 4.2; 95% CI: 1.1 to 20.4) and (OR = 1.89; 95% CI: 1.02 to 3.45; P = 0.04), respectively.52,53 The use of household water treatment significantly reduced diarrhea in infants with HIV+ mothers (longitudinal prevalence ratio, 0.47; 95% CI: 0.30 to 0.73; P = 0.001) in Zambia and also reduced diarrhea in other household members (longitudinal prevalence ratio, 0.46; 95% CI: 0.3 to 0.7; P < 0.001).54 Thus, targeting the entire HIV-affected household with WASH interventions has been shown to be beneficial for PLHIV, HIV+ children, and other family members.
Compared with the standard threshold of 3 times GDP per capita, WASH programs are cost-effective stand-alone projects,32,55 but by leveraging infrastructure and resources among partner organizations, WASH interventions can be even more effective through integrated programs in health, nutrition, food security, or other community-based interventions.45,56 Integrated WASH programs can maximize the efficient use of funds, personnel, and other resources.57
Waterborne diseases are a primary burden to PLHIV, and WASH interventions are effective in reducing this burden on individuals and their households. Morbidity was the only thematic outcome of interest within this WASH review with sufficient research to generate firm conclusions. Access to an improved water supply, household water treatment, and hand-washing with soap consistently reduced the prevalence of waterborne pathogens and the risk of diarrheal diseases in PLHIV. Sanitation interventions were also protective, although with less robust evidence. The reduction in diarrheal disease associated with these WASH interventions has been shown to slow the decrease in CD4 counts in PLHIV and to show positive impacts in those concurrently on ARV treatment. Compared with the standard threshold of 3 times per capita GDP, WASH interventions were also cost-effective for PLHIV, HIV-affected households, and the greater community. Although additional research is required to address the behavioral aspects of sanitation and hygiene and further strengthen the nexus between WASH and other sectors, the evidence is clear that WASH interventions are incrementally beneficial to PLHIV and their families.
The authors thank the CDC librarians, Gail Bang and Emily Weyant, for their help conducting database searches and compiling abstracts; Michal Tchuenche for assisting with the cost-effective analysis; and Rachel Peletz for contributing to the systematic review.
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