Fever After a Stay in the Tropics: Clinical Spectrum and Outcome in HIV-Infected Travelers and Migrants

Travelling with HIV in the XXI century: Case report and narrative review

The number of migrants and travellers has grown in recent decades. This phenomenon is also true of people living with HIV, given their much-improved life expectancy and quality of life. A significant number of travellers with HIV are migrants returning to their home countries to visit friends and relatives (VFRs). This population constitutes a high-risk group because they travel for longer and often to rural and remote areas and have closer contact with the local population. In this review we discuss the sociodemographic characteristics of travellers with HIV, the differences between conventional travellers and VFRs, and the risks of HIV acquisition and transmission during travel. We also present the most relevant travel-associated illnesses and highlight the particularities of pre-travel advice given to this population, including immunosuppression, responses to vaccines, high incidence of comorbidities, drug interactions, legal and language barriers. The need to integrate these factors based on far less evidence than that available for the general population makes pre-travel advice for travellers with HIV genuinely challenging.

Fever in the Returned Traveler

International travel is associated with a risk of infections not typically seen in high-income settings. Malaria is the most important tropical infection in travelers, but epidemics of dengue, chikungunya, and Zika emphasize that clinicians need to be aware of the rapidly changing distribution of many arboviruses. A detailed travel history and a syndromic approach to the investigation and management of patients is key. Consultation with a specialist is often recommended to ensure that appropriate management and investigations are undertaken in febrile returned travelers.

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Travel, especially to low-income regions, is associated with an increased risk of infections not typically seen in high-income countries (e.g., malaria, enteric fever, dengue, chikungunya, Zika, and schistosomiasis).

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Although gastroenteritis, respiratory tract infections, and self-limiting viral infections are common, a minority of patients will have a potentially life-threatening tropical infection.

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The evaluation of an ill returned traveler requires a detailed travel history with an understanding of the geographic distribution of infections, risk factors for acquisition, incubation periods, clinical presentations, and appropriate laboratory investigations.

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A syndromic approach to specific investigations, and to presumptive therapy pending laboratory confirmation of the diagnosis, is appropriate.

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Travel is also a risk factor for acquisition of antimicrobial-resistant bacteria, such as those containing extended spectrum β-lactamases, that become part of the traveler's colonizing flora.

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As a rule, malaria should be excluded in all travelers presenting with a fever who have visited the tropics.

Travel vaccination recommendations and infection risk in HIV-positive travellers

BACKGROUND

With the advent of highly active antiretroviral drugs for the treatment of human immunodeficiency virus (HIV) it has become possible for people with HIV to travel to destinations that may place them at risk of a number of infectious diseases. Prevention of infections by vaccination is therefore of paramount importance for these travellers. However, vaccine responsiveness in HIV-positive individuals is not infrequently reduced compared to HIV-negative individuals. An understanding of the expected immune responses to vaccines in HIV-positive travellers is therefore important in planning the best approach to a pretravel consultation.

METHODS

A PubMed search was performed on HIV or acquired immune deficiency syndrome together with a search for specific vaccines. Review of the literature was performed to develop recommendations on vaccinations for HIV-positive travellers to high-risk destinations.

RESULTS

The immune responses to several vaccines are reduced in HIV-positive people. In the case of vaccines for hepatitis A, hepatitis B, influenza, pneumococcus, meningococcus and yellow fever there is a good body of data in the literature showing reduced immune responsiveness and also to help guide appropriate vaccination strategies. For other vaccines like Japanese encephalitis, rabies, typhoid fever, polio and cholera the data are not as robust; however, it is still possible to gain some understanding of the reduced responses seen with these vaccines.

CONCLUSION

This review provides a summary of the immunological responses to commonly used vaccines for the HIV-positive travellers. This information will help guide travel medicine practitioners in making decisions about vaccination and boosting of travellers with HIV.

Travel-related health events and their risk factors in HIV-infected sub-Saharan migrants living in France and visiting their native country: The ANRS VIHVO cohort study

BACKGROUND

Literature on health events in HIV-infected travellers is scarce, particularly in sub-Saharan African (SSA) migrants.

METHODS

We investigated health events in HIV-infected SSA migrants living in France during and after travel to their native country. All had a pre-travel plasma viral load (pVL) below 200 copies/mL and were on stable combined antiretroviral therapy (cART). Logistic regression models were used to assess the risk factors for at least one adverse health event or febrile event.

RESULTS

Among 264 HIV migrants, pre-travel median CD4 count was 439/mm3 and 27 migrants (6%) experienced a low-level viremia between 50 and 200 copies/mL. One hundred (38%) experienced at least one event (13 experienced two events). The most common events were gastrointestinal, including diarrhoea (n = 29, 26%), respiratory events (n = 20, 18%), and malaria (n = 17, 15%; 1 death). In multivariable analysis, a pre-travel low-level viremia and a lack of pre-travel medical advice significantly increased the risk for any event (OR 4.31, 95% CI, 1.41-13.1; and OR 3.62, 95% CI, 1.38-9.47; respectively). A lack of pre-travel advice significantly increased the risk for febrile event.

CONCLUSIONS

Early and tailored counselling on pre-travel medical advice regarding diarrhoea and vector-borne diseases prophylactic measures in HIV-infected SSA migrants should be emphasised before travel to Africa.

Symptoms of infectious diseases in HIV-positive travellers: A prospective study with exposure-matched controls

BACKGROUND

Recently, the number of HIV-infected travellers to (sub)tropical areas has increased substantially. In the Netherlands, HIV-positive travellers with CD4-cells of <500/mm³ are advised to carry stand-by antibiotic treatment against travellers' diarrhoea. Our aim was to determine whether HIV infection is associated with travel-related symptomatic diseases.

METHODS

A prospective study was performed among HIV-infected travellers and age-matched HIV-uninfected travel companions serving as controls, attending two travel clinics in Amsterdam. Participants filled out daily questionnaires before, during, and after their trip.

RESULTS

Overall, 52 pairs were included. All participants were male, and 91.3% were born in a Western country. Prevalence of travel-related diarrhoea was 50% among HIV-positive travellers and 40% among controls. No significant differences were observed for incident travel-related diarrhoea (incidence rate ratio = 1.60, 95%CI = 0.79-3.27) or duration of symptoms (odds ratio = 1.49, 95%CI = 0.65-3.45). There were no significant differences in symptom incidence or duration for travel-related vomiting, cough, rhinitis, pruritus, fatigue, or nausea. Only 6.3% of HIV-positive travellers with CD4-cells of <500/mm³ and diarrhoea used their stand-by antibiotic treatment as recommended.

CONCLUSION

Travel-related symptoms were not significantly more frequent or longer lasting among HIV-infected travellers compared to controls. Most HIV-infected travellers with CD4-cells of <500/mm³ and diarrhoea did not take stand-by antibiotic treatment. These results may question the need for routine prescription of stand-by antibiotics among this specific risk group. Further research, especially among HIV infected VFR travellers and in larger study groups is needed.

Impact of HIV infection on severity of imported malaria is restricted to patients with CD4 cell counts < 350 cells/microl

OBJECTIVES

To study the relative impact of HIV-1 infection and associated immunodepression on the severity of Plasmodium falciparum malaria in adults returning from areas of endemic malaria.

METHODS

We conducted a cross-sectional study, based on data from 104 HIV-infected patients from the French Hospital Database on HIV cohort (FHDH-ANRS CO4) and 161 HIV-negative patients from Bichat hospital, with a diagnosis of imported P. falciparum malaria between 2000 and 2003. The severity of falciparum malaria episode was graded with World Health Organization (WHO) criteria 2000 or on 2007 French recommendations.

RESULT

Depending on criteria used, 40% (WHO) and 28% (2007 French recommendations) of episodes of imported P. falciparum malaria in HIV-infected patients were classified as severe, compared with 21% (WHO) and 11% (2007 French recommendations) of episodes among HIV-negative patients. Among HIV-infected patients, the episodes were severe in between 22 (CD4 cell counts > or =350/microl) and 51% (CD4 cell counts <350/microl) of cases using WHO criteria, and between 12 (CD4 cell counts > or =350/microl) and 41% (CD4 cell counts <350/microl) of cases using 2007 French recommendations criteria. Relative to HIV-negative patients, after adjusting for confounding factors, HIV-infected patients with severe immunodepression (CD4 cell counts <350/microl) were at a significantly higher risk of severe malaria than HIV-negative patients (odds ratio 3.2-4.7, depending on the criteria) contrary to HIV-infected patients with CD4 cell counts more than 350/microl (odds ratio 0.7-0.9).

CONCLUSION

The association between HIV infection and severity of imported P. falciparum malaria is only observed for HIV-infected patients with severe immunodepression (CD4 cell counts <350/microl).

Fever in returned travellers presenting in the United Kingdom: recommendations for investigation and initial management

International travel is increasing. Most physicians and general practitioners will encounter returned travellers with fever and the majority of travel-related infection is associated with travel to the tropics. In those returning from the tropics malaria must always be excluded, and HIV considered, from all settings. Common causes of non-malarial fever include from Africa rickettsial diseases, amoebic liver abscess and Katayama syndrome; from South and South East Asia, enteric fever and arboviral infection; from the Middle East, brucellosis and from the Horn of Africa visceral leishmaniasis. Other rare but important diseases from particular geographical areas include leptospirosis, trypanosomiasis and viral haemorrhagic fever. North and South America, Europe and Australia also have infections which are geographically concentrated. Empirical treatment may have to be started based on epidemiological probability of infection whilst waiting for results to return. The evidence base for much of the management of tropical infections is limited. These recommendations provide a pragmatic approach to the initial diagnosis and management of fever in returned travellers, based on evidence where it is available and on consensus of expert opinion where it is not. With early diagnosis and treatment the majority of patients with a potentially fatal infection related to travel will make a rapid and full recovery.