Adult Travelers with HIV Infection

Pre-travel health advice for human immunodeficiency virus-infected travelers, from Rio de Janeiro

Counseling for human immunodeficiency virus infected travelers is becoming increasingly specialized. Previous studies have reported the experience of HIV-infected travelers from temperate-climate countries but little is known about HIV-infected travelers from tropical countries. A retrospective study was conducted on HIV-infected travelers presenting at a travel health clinic in Rio de Janeiro. Eleven journeys by ten people were recorded. Brazil (Amazon region and Northeast) was the destination for six journeys. Other destinations were Peru, Angola, Europe and Asia. Nine attendees were undergoing antiretroviral therapy. Few HIV-infected people from Rio de Janeiro consulted a travel medicine specialist before traveling. Since they travel to destinations in Brazil and abroad where there are endemic diseases not encountered in Rio de Janeiro, careful pre-travel planning needs to be undertaken. Strategies for increasing the frequency of pre-travel consultations need to be developed, such as closer collaboration between HIV clinics and travel health clinics.

Recomendaciones al viajero en situaciones especiales

The increase in the hope and quality of life, along with the greater rapidity and comfort of the different means of transport have made possible that travellers with chronic diseases, pregnant and kids makes tourist trips to tropical or subtropical zones. On the other hand the increase of the international cooperation has caused the appearance of long stay travellers who live in conditions such as the local population. These travellers have special characteristics due to their physical training conditions, chronic treatments, or the way of life during the travel that them makes more susceptible to suffer problems of health during the travel. For this reason the usual recommendations for travellers are insufficient in these groups and is necessary to make an individualized travel advice that considers these factors. This revision shows the most important warnings that must be made in these groups of special travellers.

Pharmacotherapy, vaccines and malaria advice for HIV-infected travellers

Since the introduction of effective antiretroviral therapy (ART), HIV-infected individuals are travelling more frequently and international travel has become much safer. Specific concerns include the safety of ART during travel, drug adherence and interaction considerations, and effects of immunosuppression. This review describes potentially important infections, vaccine effectiveness, safety and special approaches for their use, and HIV-related issues regarding predeparture counselling. With advanced immunosuppression (CD4+ T-cell count < 200/microl or < 14%), the immunogenicity of several vaccines is reduced, complications could occur after live attenuated vaccines and certain infections acquired during travel may be more frequent or severe. Challenges include the best options for malaria chemoprophylaxis, standby treatment and medical follow-up of the increasing number of HIV-infected long-term travellers.

Pre-travel preparation and outcome of HIV-infected travellers from a UK clinic

Objectives. To review the pre-travel preparations and travel health outcomes of HIV-infected individuals. Methods. A prospective questionnaire-based study among English speaking adults with HIV infection attending an outpatient clinic from July to November 2000. Results. Baseline and follow-up questionnaire data were available for 34 individuals whose median CD4 count was 451 cells/mm(3). Eleven of these (32%) had sought travel advice before departure. Eight (23.5%) had been vaccinated or were planning vaccination against at least one condition and 17 (50%) listed travel-specific medications they planned to take with them. Those who were travelling to Africa were more likely to be vaccinated than those who were not travelling to Africa (3/4 vs 5/30, respectively, P=0.03). Those travelling to Europe were less likely to be vaccinated than those who were not (1/16 vs 7/18, P=0.04). The median duration of travel was 14 days (1-180). Fifteen subjects (44%) became ill while abroad. Those who became ill abroad were more likely to have visited Asia (P=0.003) and less likely to have visited the Americas (P=0.02) than those who did not become ill abroad. In addition, they tended to have stayed abroad for longer periods (P=0.07) and had visited more countries (P=0.04) than those who did not become ill abroad. Sixteen individuals (47%) reported illness on their return to the UK. Conclusions. HIV-infected travellers have an increased susceptibility to opportunistic and other travel-related infections and the need for appropriate advice, vaccination and prophylactic therapy is important. Health care provision in this field is in need of uniform guidelines to coordinate travel health management for this particular high risk group.

Drug use, travel and HIV risk

A study was conducted to examine the travel experiences of a community sample of 160 drug users and 44 non-users recruited as part of a study of HIV risk. Of the sample, 47% (96/204) reported intercity travel in the previous ten years. Results showed that men were more likely to travel than women, Anglos more than minorities, and young persons more than old. When travellers testing HIV-seropositive (n = 13) were compared with seronegative travellers, HIV-positive travellers reported more sex while travelling than HIV-negative persons, but virtually all of the difference reported involved sex with condoms. There were no significant differences in sex risk behaviours while travelling between drug users and non-drug users, or in sex risk behaviors between drug injectors and non-injectors. Travellers had fewer injection partners while travelling than they had while at home. There was also a significant difference in number of sex partners with whom a condom was not used, with fewer sex partners while travelling.

Preparation of the HIV-infected Traveler to the Tropics

Pre-travel advice and planning can help the HIV-infected traveler minimize the unavoidable risks of tropical travel. Issues to cover: the diagnosis, staging, and stabilization of HIV infection and its sequelae; adequacy of the supply of medications currently used; optimal sources of medical care in planned destinations; potential HIV-related legal restrictions on travel; special risks associated with the medical geography of the traveler's route and planned activities; the need to avoid food-, water-, and vector-borne diseases; any appropriate vaccination, chemoprophylaxis, and antimicrobial agents; and arrangement for adequate medical follow-up upon the traveler's return.

The human immunodeficiency virus-infected traveler

As the number of travelers from industrialized countries who are infected with human immunodeficiency virus (HIV) increases as a consequence of the clinical benefits of highly active antiretroviral therapy (HAART), updated prophylactic knowledge is needed. Vaccine prophylaxis must balance the safety and immunogenicity of vaccines with the estimated risk of acquiring the disease. Further research is needed on antimalarial chemoprophylaxis for travelers who are HAART recipients, because of possible pharmacokinetic interactions. Safe sex practices must be adopted to avoid both spreading of the infection in the host country and superinfection with different HIV strains. Most individuals infected with HIV may travel safely, even though the infectious risk has been reported to be higher for patients with advanced infections than for the general population. These patients are also less likely to produce an effective immune response to vaccines. Migrants and refugees from poor countries are also at risk of acquiring HIV infection. Their legal-residency status may often prevent their access to adequate health services, thus necessitating urgent public health actions.

HIV and the returning expatriate

Worldwide seroprevalence of the Human Immunodeficiency Virus (HIV) was estimated at 29.4 million at the end of 1996 with 75-85% of infections in adults transmitted through sexual intercourse, and by heterosexual intercourse in more then 70%. SubSaharan Africa is currently the area most heavily affected but over the past 5 years rapid spread of the virus has occurred in Asia. No developing country is free of HIV infection and HIV infection acquired abroad now accounts for most of heterosexually acquired HIV infection presenting in the (United Kingdom) UK, accounting for 25% of new HIV cases in the UK in the year to end March 1995 and 18% in the year to end March 1996, and at least 38% of new cases in Scotland in 1996.

The compromised traveler

Compromised travelers represent a diverse and challenging group of individuals. They include HIV-infected patients who are at risk for potentially adverse reactions to immunizations, and new exposures to enteric water-borne opportunistic pathogens associated with chronic infections. Such travelers may encounter unfamiliar opportunistic fungi and classical tropical infections, such as leishmaniasis, whose pathogenesis can be enhanced by the presence of prior HIV infection. Other immunocompromised groups include those who are functionally or anatomically asplenic, and patients who are iatrogenically immunosuppressed from medications utilized for solid organ transplantation, chemotherapy, or treatment of malignancies. This population of travelers also includes those with diabetes mellitus who may require adjustments in their dosing, administration, and possibly even the types of insulin used on their trips. These patients are also at greater risk for acquisition of tuberculosis, severe community-acquired pneumonia, urinary tract infections, and pyomyositis. Older travelers present both the infectious disease and travel medicine specialist with issues such events, malignancy-related infections, myocardial infarction, and other forms of cardiopulmonary compromise, which the authors address in this article.