title: The impact of water, sanitation, and hygiene interventions on the health and well-being of people living with HIV: a systematic review.
abstract: BACKGROUND
  Access to improved water supply and sanitation is poor in low-income and middle-income countries. Persons living with HIV/AIDS (PLHIV) experience more severe diarrhea, hospitalizations, and deaths from diarrhea because of waterborne pathogens than immunocompetent populations, even when on antiretroviral therapy (ART).
  
  
  METHODS
  We examined the existing literature on the impact of water, sanitation, and hygiene (WASH) interventions on PLHIV for these outcomes: (1) mortality, (2) morbidity, (3) retention in HIV care, (4) quality of life, and (5) prevention of ongoing HIV transmission. Cost-effectiveness was also assessed. Relevant abstracts and articles were gathered, reviewed, and prioritized by thematic outcomes of interest. Articles meeting inclusion criteria were summarized in a grid for comparison.
  
  
  RESULTS
  We reviewed 3355 citations, evaluated 132 abstracts, and read 33 articles. The majority of the 16 included articles focused on morbidity, with less emphasis on mortality. 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 antiretroviral medication. We found WASH programming, particularly water supply, household water treatment, and hygiene interventions, reduced morbidity. Data were inconclusive on mortality. Research gaps remain in retention in care, quality of life, and prevention of ongoing HIV transmission. Compared with the standard threshold of 3 times GDP per capita, WASH interventions were cost-effective, particularly when incorporated into complementary programs.
  
  
  CONCLUSIONS
  Although research is required to address behavioral aspects, evidence supports that WASH programming is beneficial for PLHIV.
authors.affiliation: *Department of Civil and Environmental Engineering, Tufts University, Boston, MA; and †Waterborne Diseases Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, GA.
authors.forename: Travis
authors.initials: T
authors.lastname: Yates
authors.forename: Daniele
authors.initials: D
authors.lastname: Lantagne
authors.forename: Eric
authors.initials: E
authors.lastname: Mintz
authors.forename: Robert
authors.initials: R
authors.lastname: Quick
mesh_terms: D000328:Adult; D000349:Africa / Q000453:epidemiology; D003362:Cost-Benefit Analysis; D003906:Developing Countries; D003967:Diarrhea / Q000150:complications / Q000453:epidemiology / Q000517:prevention & control*; D015658:HIV Infections / Q000150:complications* / Q000453:epidemiology / Q000628:therapy; D006295:Health Resources; D006801:Humans; D006920:Hygiene / Q000592:standards*; D007194:India / Q000453:epidemiology; D009017:Morbidity; D017063:Outcome Assessment, Health Care; D011788:Quality of Life; D012499:Sanitation / Q000592:standards*; D014881:Water Supply / Q000592:standards*