General information Regarding HIV and Travel
Acquired immunodeficiency syndrome (AIDS), caused
by the human immunodeficiency virus (HIV), has a very long and variable
incubation period, generally lasting for many years. Some persons
infected with HIV have remained asymptomatic for more than a decade.
No vaccine is currently available to protect against infection with
HIV. Although there is no cure for AIDS, treatment with antiretroviral
therapy and prophylaxis against many opportunistic diseases associated
with AIDS are available.
International travelers should be advised that some
countries serologically screen incoming travelers (primarily those
arriving for extended visits, such as for work or study) and deny
entry to persons with AIDS and those whose test results indicate
infection with HIV. Moreover, travelers carrying antiretroviral medication
may be denied entry to some countries. Persons who intend to visit
a country for a substantial period or to work or study abroad should
be informed of the policies and requirements of the particular country.
This information is usually available from the consular officials
of the individual nations. An unofficial list by the U.S. Department
of State can be found at the following Internet address: http://www.travel.state.gov/HIVtestingreqs.html.
Specific Precautions for HIV-Infected Travelers
Primary-care providers of HIV-infected travelers
should advise their patients of the need for advance travel planning.
A pre-travel consultation with a travel health practitioner who provides
counseling and evaluates the risk-benefit balance of preventive actions
such as prophylaxis and vaccinations can minimize the avoidable risks
associated with travel.
General Concerns for HIV-Infected Travelers
Health-care providers should advise HIV-infected
travelers about the following issues:
- Travel, particularly to developing countries,
can carry substantial risks for exposure to opportunistic pathogens
for HIV-infected travelers, especially those who are severely immunosuppressed.
Discussing the itinerary with a health-care provider may identify
area- and activity-specific risks that can be addressed.
- Patients should identify sources of medical care
in the planned destination before departure and seek medical attention
promptly when ill.
- Patients should verify medical insurance coverage
and purchase additional travel insurance if necessary, though many
policies will not cover pre-existing conditions.
- Because antiretroviral medications are not available
in many parts of the world, patients should bring an adequate supply
of their medications, along with copies of prescriptions. Attention
should be given to refrigeration of medications. For extended visits,
travelers should consult with their providers in advance regarding
a plan for maintaining appropriate medical follow-up and supplies
of medications.
- Avoid changes in the medication regimen shortly
before travel, to ensure that no side effects or complications
of a new regimen occur while traveling.
Disease Prevention and Treatment
Because immune status is the major factor influencing
travel recommendations, patients should have their disease staged
before departure.
Food and Waterborne Diseases
During travel to developing countries, HIV-infected
travelers are at even higher risk for food and waterborne diseases
than they are in the United States, and many enteric infections,
such as those caused by Salmonella, Campylobacter,
and Cryptosporidium can be very severe in HIV-infected persons.
Dietary precautions are the cornerstone of prevention
against enteric infections and infections with certain other potential
opportunistic pathogens. Food and beverages especially prone to contamination
and that pose a greater risk for illness to HIV-infected travelers
include raw or unpeeled fruits and vegetables, raw or undercooked
seafood or meat, raw or undercooked eggs, tap water, ice made with
tap water, unpasteurized dairy products, and items purchased from
street vendors. Food and beverages that are generally safe include
steaming hot foods, fruits that are peeled by the traveler personally,
bottled (carbonated) beverages, hot coffee or tea, beer, wine, or
water brought to a rolling boil for >1 minute. For more detailed
information on food- and water-related precautions, especially concerning
avoidance of listeriosis, refer to the Guidelines
for Preventing Opportunistic Infections among HIV-Infected Persons2002
(MMWR Morb Mortal Wkly Rep 2002;51 [No. RR-8]). When local sources
of water must be used and boiling is not practical, certain portable
water filtration units, when used in conjunction with chlorine or
iodine, can increase the safety of water. Some units are available
that offer the effects of iodine treatment with filtration in the
same unit. For more information about how to select a proper water
filter, travelers should be advised to obtain the CDC pamphlet, “You
can prevent cryptosporidiosis: a guide for persons with HIV infection,” available
online at www.cdc.gov/travel/diseases.htm#crypto;
they may also call 1-800-458-5231 or TTY 1-800-243-7012. International
callers must dial 1-301-562-1098.
For information about waterborne infections that
may result from swallowing water during recreational water activities,
see “ Swimming
and Recreational Water Precautions” .
Chemoprophylaxis for HIV-Infected Travelers
to Developing Countries
Prophylactic antimicrobial agents against travelers'
diarrhea are not recommended routinely because of potential adverse
effects and emergence of drug resistance. In certain circumstances
(e.g., an important short-term trip to an area where the risk of
infection is very high), the health-care provider and traveler may
decide that prophylactic antibiotics are warranted after the potential
risks and benefits are weighed.
When prophylaxis is offered to travelers, fluoroquinolones
such as ciprofloxacin (500 mg once a day) are the drugs of choice
for nonpregnant adults, although increasing quinolone resistance
in Campylobacter jejuni has been reported in Thailand and
Southeast Asia. Quinolones are not approved for prophylaxis for children
and pregnant women. Trimethoprim-sulfamethoxazole (TMP-SMX) (one
double-strength tablet daily) was previously an effective prophylactic
agent against travelers' diarrhea, but drug resistance is now common
in many tropical areas. Travelers already taking TMP-SMX for prophylaxis
against Pneumocystis carinii pneumonia (PCP) may receive some
protection against travelers' diarrhea. However, prescribing TMP-SMX
solely for diarrhea prophylaxis to HIV-infected travelers who are
not already taking TMP-SMX should be considered carefully because
of high rates of drug resistance in tropical areas, high rates of
adverse reactions, and potential future need for the agent (e.g.,
for PCP treatment and prophylaxis). Use of bismuth subsalicylate
should be discussed with a travel health practitioner because it
confers only moderate protection and has the potential for causing
adverse reactions. Total duration of any chemoprophylaxis regimen
for travelers' diarrhea should not exceed 3 weeks.
Antimicrobials for Empiric Therapy
All HIV-infected travelers to developing countries
should be advised to carry an antimicrobial agent with them for empiric
use should diarrhea develop; one appropriate regimen is 500 mg of
ciprofloxacin twice a day for 3–7 days. Alternative antibiotics
(e.g., TMP-SMX, azithromycin) for empiric treatment of children and
pregnant women should be considered on a case-by-case basis. Travelers
should be advised to consult a physician if any of the following
conditions are present: severe diarrhea that does not respond to
empirical therapy, blood in the stool, fever with or without shaking
chills, or dehydration. Antiperistaltic agents (e.g., diphenoxylate
[Lomotil] and loperamide [Imodium]) can be used to relieve the symptoms
of mild diarrhea; however, they should not be used by travelers who
have high fever or blood in the stool and should be discontinued
if symptoms persist >48 hours. Antiperistaltic agents are not
recommended for HIV-infected infants, children, or adolescents.
Other precautions. Travelers should avoid
direct skin contact with soil and sand (e.g., by wearing shoes and
protective clothing and using towels on beaches) in areas where fecal
contamination of soil is likely.
Sexually transmitted diseases. The importance
of safe sex practices should be emphasized to the HIV-infected traveler
to prevent other sexually transmitted diseases, avoid transmission
of HIV to others, and prevent acquisition of different HIV strains
that may limit therapeutic options (e.g., non-nucleoside reverse
transcriptase inhibitors are not active against HIV-2). Bringing
a personal supply of condoms may be advisable, as the quality and
availability of condoms can be unreliable in parts of the developing
world.
Health-care providers should identify other area-specific
risks and instruct travelers in ways to reduce the risk of infection.
Geographically focal infections that pose high risk to HIV-infected
travelers include the following:
Malaria and other vector-borne diseases (see Disease-Specific
Recommendations for additional information). Travelers should
be advised to follow standard mosquito precautions, such as using
insect repellents, wearing long-sleeved clothing and pants when
outdoors, and sleeping in well-screened areas or with a bed net.
Malaria chemoprophylaxis for HIV-infected travelers follows the
same guidelines as those for seronegative persons. However, potential
drug interactions between antimalarials and antiretroviral agents
should be considered; for specific advice about such interactions,
contact the CDC Malaria Hotline at 770-488-7788.
Visceral leishmaniasis (VL). VL, a protozoan
infection transmitted by the bite of the sandfly, is an important
opportunistic infection in HIV-infected patients. Although >90%
of the world's cases of VL occur in Bangladesh, Brazil, India, Nepal,
and Sudan, most cases of VL and HIV co-infection have been reported
from the Mediterranean Basin (especially Spain, France, and Italy).
Clinical disease usually occurs in patients with a CD4 count <200
cells/µL as a result of reactivation of latent infection, although
primary infection has been reported. Treatment of VL with HIV co-infection
is difficult, and relapse is common. Travelers, especially those
who are immunosuppressed, should be advised to follow precautions
against sandfly bites, as described in “Disease-Specific
Recommendations: Leishmaniasis”; further details on other
regions where travelers incur risk for VL are also available in that
section. Cutaneous leishmaniasis has rarely been reported as an opportunistic
infection in HIV-infected patients.
Endemic mycoses in certain regions can also
pose a substantial risk for HIV-infected travelers. Penicillium
marneffei is endemic to Southeast Asia and southern China, and
clinical disease may occur after reactivation of latent infection
as immunosuppression increases. Penicilliosis has occurred in AIDS
patients with a remote history of only brief travel to endemic areas.
Although the environmental reservoir is unknown, soil exposure is
a known risk factor and should be avoided in those areas, especially
during the rainy season.
Coccidioides immitis, Histoplasma capsulatum,
and Cryptococcus neoformans, which cause opportunistic infections
in North America, are also present in the tropics. C. immitis is
endemic to the southwest United States, northern Mexico, and certain
areas of Central and South America, while H. capsulatum and C.
neoformans are distributed worldwide. Risk of infection can be
minimized by avoiding exposure to disturbed soil in the Americas
(C. immitis) and avoiding soil or dust exposure in areas likely
to be contaminated heavily with bird or bat guano, such as caves
or bird roosting sites (H. capsulatum and C. neoformans).
Tuberculosis. Many tropical and developing
areas of the world also have high rates of tuberculosis (see “Disease-Specific
Recommendations: Tuberculosis”).
Vaccine Recommendations
for Travelers with Altered Immunocompetence, Including HIV
Preparation for travel should include a review and
updating of routine vaccinations. At a minimum, HIV-infected adults
should be current on the routinely recommended pneumococcal, diphtheria-tetanus,
Hepatitis B, and influenza vaccines. Influenza is a year-round infection
in the tropics; in the Southern Hemisphere the influenza season is
April through September. All routine immunizations for infants, children,
and adolescents should also be confirmed and administered as appropriate.
In determining the need for other vaccinations, factors
to consider include the immune status of the patient, risk for and
severity of the disease in the destination region, and type of vaccine.
In general, killed or inactivated vaccines (e.g., hepatitis A, rabies,
meningococcus, hepatitis B, and Japanese encephalitis vaccines) should
be administered to HIV-infected travelers as recommended for non-HIV-infected
travelers. When appropriate, the inactivated forms of the polio and
typhoid vaccines should be given instead of the live, attenuated
forms. Most live virus vaccines are contraindicated, especially if
the patient's CD4 count is <200 cells/µL. The measles and
yellow fever vaccines, however, are special cases in which live virus
vaccination may be warranted (see below).
Measles vaccine is a live virus vaccine that
is recommended for most nonimmune travelers, given the increased
severity of measles in HIV-infected patients. However, measles vaccine
is not recommended for travelers who are severely immunocompromised;
immune globulin should be considered for measles-susceptible, severely
immunosuppressed travelers who are anticipating travel to measles-endemic
countries.
Yellow fever vaccine is a live virus vaccine
with uncertain safety and efficacy in HIV-infected patients. Travelers
with asymptomatic HIV infection and minimal immunosuppression, as
documented by laboratory tests such as CD4 counts, who cannot avoid
potential exposure to yellow fever should be offered the choice of
vaccination. If travel to a yellow fever zone is necessary and immunization
is not performed, travelers should be advised of the risk, instructed
in methods to avoid mosquito bites, and provided a vaccination waiver
letter. Patients should also be warned that vaccination waiver documents
may not be accepted by some countries.
—Laura
N. Broyles, Jonathan Kaplan, Phyllis Kozarsky
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