Chapter 41 The HIV-infected international traveler

Introduction

The advent of (ART) has led to significant decreases in human immunodeficiency virus type 1 (HIV-1)-related morbidity and mortality, with concomitant improved immunocompetence [1–5]. Despite this, the HIV-infected traveler is still at increased risk for opportunistic infections and other complications compared with HIV-uninfected travelers. This is especially true for those with low CD4 T-cell counts and those traveling to developing countries. Nonetheless, pre-travel health advice is often underutilized [6, 7].

One study of patients at an HIV clinic in a North American tertiary care hospital found that 46% of 290 surveyed individuals had traveled internationally within the previous 5 years. Yet, only 44% sought health advice before traveling [7]. Of those seeking pre-travel advice, only half told the provider that they were HIV-infected. International travel was associated with poor adherence to antiretrovirals (ARVs) and to risky sexual activity in these patients. A total of 93% of the 75 individuals not seeking pre-travel health advice believed such consultations were unnecessary. Such data are disturbing, given that international travel increased steadily throughout the 1990s and early twenty-first century [8]. Indeed, outbound overseas travel from the USA climbed to a high of almost 27 million by 2000 with travel to Asia, South America, and the Middle East growing by 93, 130, and 159%, respectively [7]. During this period, incident infections in returning international travelers continued to rise [9]. Post-9/11, US-international overseas travel increased to a new high of 47.7 million bidirectional visits in 2004. Countries within Eastern Europe and the Caribbean experienced the fastest growth from 2000 to 2004 (25 and 15%, respectively) [10].

There has also been increasing numbers of immigrants to developed countries who visit their countries of origin and return that are a population at high risk for tropical infections including tuberculosis (TB), malaria, food- and water-borne illnesses, hepatitis A, and sexually transmitted infections (STIs) [11]. It is therefore important that persons living with HIV/AIDS and their pre-travel providers stay informed about preparations and precautions that should be taken by the HIV-infected person when traveling internationally today.

General Considerations

The quality of pre-travel health advice can vary greatly; thus, consultation with a travel medicine specialist is advisable. A study from the United Kingdom (UK) of 215 clinicians serving higher education establishments in the UK showed that practitioners often gave good advice with respect to immunizations and malaria prophylaxis, but little on HIV and other risks [12]. Training in travel medicine was associated with more appropriate pre-travel health advice.

Pre-travel health advice for the HIV-infected international traveler should be sought as soon as possible. Consultation at least 6–8 weeks before travel is recommended to allow time for development of adequate responses to any necessary vaccinations. Use of resources such as travel clinics and travel-related websites before traveling is appropriate. Detailed counseling and evaluation of the risks and benefits of preventive prophylaxis and vaccinations are essential.

Pre-travel advice should include a discussion of immunizations, malaria prophylaxis, traveler’s diarrhea management, supplemental health insurance, accidents and injuries, motion sickness, jet lag, extremes of temperature and sun exposure, food and water safety, use of an emergency medical bracelet, list of medical services abroad, and possible arrangement of visits with physicians who speak the traveler’s language [13]. The last issue is especially important for extended visits, so that adequate medical follow-up and medication supplies are maintained. Emphasis on maintaining adherence to ARV regimens is important as there is evidence that adherence is more difficult abroad [14]. Strategies such as keeping antiretroviral medications in carry-on baggage should be reviewed. A discussion of behavioral risk reduction while traveling is also essential. Boxes 41.1 and 41.2 summarize advice on items to take while traveling and what to do while traveling that should be part of a pre-travel consultation.

Box 41.1 What to take when traveling

• Adequate supply of medications (1–2 weeks’ extra supply is advisable) and prophylactic agents (e.g. for malaria) for shorter trips, along with copies of prescriptions; attention should be given to any need for refrigeration of medications.

• Documentation of vaccinations.

• Medications for traveler’s diarrhea, e.g. ciprofloxacin for 3- to 7-day courses of treatment or daily prophylaxis up to 3 weeks’ duration; trimethoprim-sulfamethoxazole (TMP-SMX) recommended for children and pregnant women.

• Mosquito netting (preferably treated with permethrin).

• Insect repellent that contains < 30% DEET (N,N-diethylmetatoluamide).

• Medications for sinusitis and jet lag.

• Condoms and other safe-sex items.

• First-aid kit, including topical antibiotics.

• Consider bringing own equipment for boiling water, purifying water by iodine treatment, and/or filtration of water using commercial filters with 1 μm or smaller filters.

• Consider need for fluconazole, itraconazole, and isoniazid prophylaxis if CD4 count < 100 cells/mm³.

Box 41.2 What to do when traveling

• Take steps to maintain adherence to medication regimen.

• Carry securely basic medical information, e.g. medical conditions, medications, allergies.

• Know how to access local health care (general care and HIV-specific care)

• Avoid behaviors that increase risk of new infections or complications:

– “Boil it, peel it, cook it, or forget it”, and WASH HANDS.

– Avoid raw vegetables, fruit you have not peeled yourself, unpasteurized dairy products, cooked food not served steaming hot, and tap water, including ice; meat should be well-cooked, as undercooked beef, pork, or fish can be a source of tapeworms.

– Purify water in high-risk areas—boiling water is the best method of purification; tincture of iodine or tetraglycine hydroperiodide tablets is an alternative but the water must be used within a few weeks and the method cannot be relied on to kill Cryptosporidium unless the water is allowed to sit for 15 h before it is drunk; filtering water produces variable results, especially for small bacteria or viruses, and proper selection, operation, care, and maintenance of water filters are essential.

– Avoid walking barefoot in areas with high risk of soil pathogens.

– Avoid swimming in bodies of water that may be contaminated by other people and from sewage, animal wastes, and wastewater run-off; avoid swallowing water when swimming, even chlorinated water, which may contain live organisms (e.g. Cryptosporidium, Giardia, hepatitis A virus, and Norwalk virus), and which have moderate to very high resistance to chlorine; avoid swimming in areas of endemic schistosomiasis or water at risk of contamination from animals carrying Leptospira.

– Use safe-sex practices to avoid risks from acquiring sexually transmitted diseases. These risks include increased severity and complications (e.g. herpes outbreaks more prolonged and severe), risks related to acquiring new HIV strains (e.g. non-nucleoside reverse transcriptase inhibitors are not active against HIV-2).

– Avoid blood exposures (e.g. acupuncture, tattoos, injections with possibly unsterile needles, sharing razors, manicures and pedicures) that can lead to acquiring hepatitis C as hepatitis C-related cirrhosis is accelerated in those co-infected with HIV.

It is wise to reassess the stage of HIV prior to travel as low CD4 counts are the biggest predictor of risk of opportunistic infections (OIs) when traveling. However, changing antiretroviral medications just prior to travel is not encouraged in order to avoid complications from the ARVs occurring while traveling. The Centers for Disease Control and Prevention (CDC) suggest that to minimize the risk of infection, treatment naïve HIV-infected individuals with CD4 cell counts below 200/mm³ should delay travel if possible until CD4 T-cell reconstitution with ART occurs.

The CDC also warns that some countries screen for HIV and deny entry to those who have AIDS or test positive for HIV (usually those entering for extended periods, e.g. for work or study). Some countries further deny entry to those carrying antiretroviral medications. Placing ARVs in an empty vitamin or other medication container is one means of avoiding problems in such situations. More specific information is best obtained from the consular officials of the individual nations. See Box 41.3 for a list of travel resources.

Box 41.3 Useful travel resources

• CDC Travelers’ Health site: http://www.cdc.gov/travel/index.htm

• CDC Malaria webpage: http://www.cdc.gov/malaria

• CDC Information Line: 1-877-CDC-INFO or 1-800-232-4636, toll free. Choose international travel option at the prompt

• World Health Organization (WHO) homepage: http://www.who.int/en

• WHO International Travel and Health page: http://www.who.int/ith/en

• US State Department Travel Warnings and Consular Information: http://travel.state.gov/travel/cis_pa_tw/tw/tw_1764.html

Vaccinations

Concerns over vaccinating HIV-infected persons because of documented elevations in HIV viral loads have not borne out. Such viral load elevations are transient, resolving within 4–6 weeks and sooner if on ART without any documented long-term deleterious effects [15]. All HIV-infected travelers should therefore be uptodate on routinely recommended vaccines and those routinely recommended for HIV-infected individuals. Additional vaccines should be given based on the specific travel risk exposures to endemic infections. It should be noted that vaccine responses are generally inadequate if the patient’s CD4 count is < 100 cells/mm³; best results are obtained if the CD4 count is > 350 cells/mm³ [16]. The CDC’s Yellow Book states that antiretroviral drug-induced increased CD4 counts, and not nadir counts, should be used to categorize HIV-infected persons and that waiting 3 months post-immune reconstitution before immunization is advisable.

In general, inactivated vaccines are safe to administer and should be initiated 6–8 weeks before travel. Live vaccines, including BCG, should be avoided with two exceptions (Table 41.1):

• Live measles vaccine is recommended for non-immune travelers whose CD4 counts are > 200 cells/mm³ as the clinical course of the disease is worse in those with HIV. Non-immune travelers with CD4 counts < 200 cells/mm³ should receive the immune globulin if traveling to endemic areas (CDC, Yellow Book).

• Yellow fever vaccine is of unknown risk and benefit to HIV-infected individuals; however, it should be offered to asymptomatic HIV-infected individuals with minimal immunosuppression (avoid if CD4 counts < 200 cells/mm³) who cannot avoid potential exposure to the yellow fever virus. Those at risk who defer immunization should be instructed in methods to avoid mosquito bites and provided a vaccination waiver letter understanding that such a letter may not be accepted by some countries (CDC, http://www.cdc.gov/travel/hivtrav.htm).

Table 41.1 Summary of vaccination recommendations

Routinely given	Given if travel indicates	Contraindicated
• Tetanus–diphtheria (Td or Tdap vaccines) • Hepatitis A • Hepatitis B • Influenza (inactivated) • Pneumococcal polysaccharide vaccine (H. influenzae B generally not recommended as HIV-infected adults are generally infected with non-typeable strains; children should be vaccinated)	• Japanese B encephalitis (many side effects not unique to HIV-infected persons; use if at high risk, e.g. > 1 month in rural endemic area) • Measles (live vaccine should not be given if severe immunosuppression; use immunoglobulin if needed) • Meningococcal (consider either the polysaccharide or conjugate vaccine) • Polio, inactivated (IPV) • Rabies (safe; pre-exposure prophylaxis generally not indicated) • Tick-borne encephalitis (only if high risk, e.g. forested endemic areas and drinking unpasteurized milk products) • Typhoid Vi (inactivated, Vi) • Yellow fever (live vaccine should not be given if severe immunosuppression, instruct how to avoid mosquito bites and provide a vaccination waiver letter)	• BCG • Polio, live • Typhoid, live • Influenza, live attenuated (LAIV) • Varicella-zoster virus (VZV; can consider if CD4 count > 200 cells/mm³) (cholera vaccine no longer recommended or required)