There was skit on Saturday Night Live a while back that in very biting fashion parodied a commercial for adult diapers. The product being promoted in the piece was a diaper named “Oops, I Crapped My Pants”. The political incorrectness of satirizing an unfortunate physical condition, in this case fecal incontinence, aside, it was I thought quite funny in a very sick sort of way and something I could relate too personally. What often makes humor good is when there is recognition on the part of the viewer. That is what I think made Seinfeld so good, those writers took simple everyday events most of us have had happen to us and had us rolling on the floor at the absurdity of it all.

So you may ask what is my connection with fecal incontinence. Well if you have been on a couple of the current Protease Inhibitors (HIV medications) out there known for this problem you don’t have to ask! I have heard dozens of variations from my patients over the past few years of the humiliating event summed up so succinctly as “Oops, I Crapped My Pants”. In fact, I have several folks who absolutely refuse to take particular HIV medicines because they cause this problem and the best medicines we have to control it do not work for them.

One of my favorite, but very sad, stories involves a fellow who called me on his cell phone from the #15- Colfax bus to let me know he had just crapped his pants and there was no way he was ever going to take those “fucking pills” again. I was able to totally relate. Further on here I am going to share some success stories I have had in controlling this problem using a simple, harmless, and probably much needed mineral supplement, calcium. Before I go there though I am not ready to let go of this one just yet.

Diarrhea out of nowhere is actually less common than the quandary “is this a fart or shit?” Personally, I learned on more than one occasion that it was not gas! This of course rarely happens at home five feet from the toilet, shower and clean underwear and/or pants depending on the size of the event. One of my clients never leaves home with out baby butt wipes and a clean pair of shorts in his backpack. For some odd reason these events tend to occur with frightening frequency on the bus or in the car stuck in traffic! Or my favorite is at some public event, especially one you really want to be at, like a concert or something. For example, I was not about to let anything interfere with the Allman Brothers launching into 30 minutes of Mountain Jam at Red Rocks last summer, not even a little crap in my pants. Besides it was a windy night and everybody was pretty stoned. “Do you smell shit? No I don’t smell shit. Sounds pretty fucking far out to me”!

Of course if you are stuck somewhere you do not want to be, having just crapped your pants can provide a great out, especially if you are stinking up the room. No other phrase has the power to get you out of something than “sorry, I’ve got to go, I’m having diarrhea”. This excuse is virtually never challenged!

Even when it is just a gas event it can often occur with little or no warning and medication farts for some reason are never the silent types. Slow elevator rides seem to evoke long and loud farts. I have never quite figured out why elevator rides cause farting, but perhaps it is the upward movement counter to gravity that pulls it out. There is a perverse pleasure in really letting one rip if you are the only person on the elevator though. I have always wondered what the next person on must think!

Fortunately I work with very tolerant people or else they are deaf and this includes the patients I see! I rarely get confronted on passing gas in a small or crowded room. There are a couple comebacks that you usually can slip in before people gather their wits to say something. A loud fart leaves most people speechless at least for a few seconds so it gives you time to control the moment. One of my favorites is ‘oops, hope I didn’t get any on you”. Another little less crude one is “goddamn those pills, they are turning me into a social pariah”. This last response also will frequently get you off the embarrassment hook and evoke sympathy! The best of both worlds!

Farting in public though can be great practice for you if you are planning an acting career. You become very adept at looking totally clueless or perhaps incredulous. You get great at shifting the blame to the poor unsuspecting fool next to you. I have actually gotten another person in the room to apologize for my gas!

So what can be done about these annoying problems. You can always stop the offending drug but this is often not the best option when trying to control your HIV with a potent cocktail of medicines that often do their intended job of controlling viral load very well. The knee jerk response in our culture is often to ask for another pill to control the side effects of some other medication. As a rule of thumb it would probably be beneficial to try other alternatives first. When discussing this problem with folks there are a couple of frequent compounding factors that I often explore first as sources of aggravation for the problem.

It is usually worth it to bring a bit (at least a full cup, the watery the better) of the stuff in to be tested for parasites. Gay men in particular may have picked up one or another critter over the years and I do think that sometimes the HIV medicines reactivate them. A better immune response may actually be responsible for the reactivation. Anyway if the diarrhea is particularly intense and nothing seems to help get the stuff tested for parasites!

Caffeine and alcohol are often very gut stimulating substances and should be avoided or significantly curtailed if you are on HIV medicines and diarrhea is a problem. I personally have found that a certain protease inhibitor in the morning along with a couple strong cups of coffee creates a truly prolonged and explosive experience. The new environmentally sensitive low flush toilets are a real burden in this situation. You wind up flushing three or four times per dump and probably have to clean the stool several times to boot. Can’t you see the headlines now: “AIDS drug single-handedly responsible for environmental catastrophe”.

If the curtailing of caffeine and alcohol doesn’t help there are other dietary changes that might. The first is to increase bulk/fiber in the diet. Yes, this is often the treatment for constipation but it actually works well in both directions. Metamucil can be a drag to get down every day but it is cheap and often very effective and very benign on the system. The American diet is notorious for its lack of fiber. Fruits, vegetables and whole grains can add plenty of fiber and they are cheap and good for you! One side effect of more fiber though can be more gas even though it helps with the diarrhea.

An interesting discovery, validated by not only by some clinical research but also lots of day to day experience with my own patients, is that taking calcium supplements really can help with this form of diarrhea. 500 milligrams twice a day seems to do the trick. This all has to do with the push and pull of water in and out of the gut. That is water retained often translates into more liquid stool.

Watch out though because calcium supplements often come combined with magnesium and too much of that mineral can actually cause diarrhea. Though I must say that a combination of twice as much calcium as magnesium worked well for me and many of the calcium supplements available are a combination. Magnesium alone though usually causes diarrhea. It is not too difficult though to find a plain and easily affordable calcium tablet that does not have magnesium in it.

Many of the “traditional” medications used to treat diarrhea are actually paralytics and they slow movement of stuff through the gut by paralyzing the muscles lining the intestine, I assume, giving more time for water to be absorbed out of the gut, I strongly advise that you try to control the problem with a more natural approach and avoid these drugs if at all possible. The two most common are lomotil and Imodium.

In closing I would like to remind everyone that even though these HIV drugs do work well and are necessary for our survival the use of them does come with trade offs. They are powerful chemotheraputic agents and sticking with them on a regular, ongoing basis is never easy! Try hard to work with your care providers around the not insignificant side effects and you will be surprised what you can get used to and the benefits that can be had. Dying of AIDS gets real old fast!

The drug companies selling these chemicals would serve us all better with a bit more honest approach than is currently used in their ubiquitous advertising. Get rid of the buff models riding bikes, climbing mountains etc. and instead show some poor soul with sunken cheeks, a pot belly and a scrawny ass holding a pair of shitty underwear with the caption “Oops, I crapped my pants, again, but I am not dying of AIDS”!

Having AIDS is a fucking drag and the therapies we currently have, though they can be effective, often stink in a big way too! The false illusion created by the corporate advertising of these medicines is unfortunately lulling many into thinking that AIDS is now a manageable problem. Not true! If you are at risk for HIV in this country i.e. gay, smoking crack and paying for it with money from sex or shooting drugs and sharing needles or having sex with someone who does, don’t fool yourself, the “cure” ain’t easy!

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