Travel Medicine and HIV positive Traveler

Tuti Parwati Merati Division of Tropical and Infectious Disease, Department of Internal Medicine, Faculty of Medicine, Udayana University, Bali

Demographics ofInternational Travel in HIV InfectedPatients

Pre-HAART (Kemper et. al. 1992-93) Survey in hospital- ased HIV clinic! "alifornia #$% had traveled &ithin 'S( )*% &ith foreign travel &ithin) years +edian "D#,-)*.mm/ Reason for travel0
/*% thought last chance to travel

Demographics ofInternationalTravel inHIV InfectedPatients

Post-HAART (Sherrard 1997-2007) International Health "linic! 1tta&a! "anada 23% foreign orn0 travel to visit friends and relatives #/% "anadian orn0 travel for vacation and usiness +edian "D# , ##*.mm/ Destinations0 4in order5

Su -Saharan Africa "ari ean "entral America Sherrard and McCarthy. South Asia Travel Medicine and Infectious Disease 2009; 7:291 29!. S6 Asia
"e#$er et. al. % Travel Med 199!; 2: &! &&.

T e purpose of t is presentation
!urrent "lo#al $ID% %ituation and HIV Infection &is' of ac(uirin) HIV infection durin) international travel $ddresses t e issues of HIV screenin) of international travelers *ffers advice to prevent HIV infection durin) international travel &ecommendation provided for medical counselin) of t e prospective traveler w o is HIV positive + on ealt precaution, prop ylactic medication and immuni,ation-

7hat is the trigger of HIV epidemic in Asia 8 Asia population 0 /9- illion
10 million 10 million Women sell sex

75 million
(2-20% adult male)

Male !"

Men in Asia had sex With CSW

10 million
MSM

50 million
Women married With men who had sex with CWS

Male

Female

n#ant $ Children

TR6:D 1; HIV PR6VA<6:"6 A+1:= ;6+A<6 S6> 71R?6RS 4D6:PASAR! @A<I5 25

20 22.5 20.5

% 15
10 5 0 1.6 7

DIR6"T S6> 14.5 15.2 71R?6RS 12.4

8.8 8.5 4.1 6.1 7.2

I:DIR6"T S7 4 2 2 0.25 0.24

2000 2001 2004 2005 2006 2007 2008 2009 2010

%ource. Bali Healt Department

T&/0D *F $ID% *0 DIFF/&/0T &I%1 F$!T*&% *0 P/&I*D% *F TIM/ I0 I0D*0/%I$

100 90 80 70 60 Persen 50 40 30 20 10 0 17.6 11.8 5.9 0 87-90 2.1 1.05 0 91-95 17.6 7.7 2.2 0 96-2000 Ta(un Homosex Heterosex ID !"#$-%"#$ &"k '#ket"(u# 64.7 53.7 43.2 36.6 53.3 50.5 39.5 72.5

5.5 3.4 1.3 2001- 2005

3.4 2.6 4.0 2006-skrg

Sumber : Laporan Triwulan Pengidap infeksi HI dan !asus "I#$ $ep%e&'er 2008

HIV PR6VA<6:"6 A+1:= ID's! D6:PASAR! @A<I

80 70 60 6) 71 61 58 64

% 50
40 )0 20 10 0 2000
%ource. Bali Healt Department

200)

2004

2005

2007

TR6:D 1; "1:D1+ 'S6 4I:T6RVI67 7ITH S6> 71R?6RS5

80 70 60 50 40 )0 20 10 0 2007 2009 2010
Percent condom use last seB 7)

66
Percent al&ays use condom &ith clients in the 4) last &eeA )8

)4

"HA<<6:=6S I: I:"R6ASI:= "1:D1+ -'S6

2 <o& argaining position among seB &orAers 4lo& education! poverty5 2 High mo ility of ;S7 2 Socio-political environment 4illegality! priority of issues5 2 Issue of morality 2 <o& demand of condom use among male clients

Sex workers/or IDU as the epicentrum of HIV transmission

Children

Clients wife
Clients

SW
Clients

ID

Clients wife
Children

"ountry U%$ +FloridaU%$ +Miami and 0ewar'3ondon Paris "ermany Italy %wit,erland 0et erlands !entral, /astern, %out ern $frica 4est $frica $sia 5 Pacific

HIV Positive Rate of ;S7 4%5 6 5 768 659 659 : 76 ; <= +%4 w o are IDU-

ID's 4%5 65< :? ; A<

> ; ?6 @ ; 7? 6;>

Initial TravelPreparation
"hecA entryrestrictionsforHIVtravelers Travel health insurance
+edical care HospitaliCation 6vacuation

1 taining medical care a road

HIV %creenin) of International Travelers

$ccordin) to 4H* ; IH& . t e only document t at can #e re(uired from international travelers is a valid certificate of vaccination a)ainst Bellow FeverC But some proposed re(uirin) HIV statusC $fter more careful considerations , @6 countries ave a#andoned HIV screenin) , #ut A6 countries still ave policies t at discriminate travelers and mi)rants wit $ID% and HIV Infection $ctually, no screenin) pro)ram, even if applied to all enterin) traveler could

HIV ;inal Rule

%UMM$&B. *n 0ovem#er 9, t e Department of Healt and Human %ervices, !enters for Disease !ontrol and Prevention +HH%D!D!-, pu#lis ed a Final &ule in t e Federal &e)ister t at will remove HIV infection from t e list of communica#le diseases of pu#lic ealt si)nificance and remove references to HIV from t e scope of medical eEaminations for aliensC T e final rule will )o into effect on Fanuary @, 96:6C T is ca#le provides )uidance to posts for andlin) cases involvin) HIV after Fanuary @, 96:6,

Reference Document0 %T$T/ :9=>:@, :9D6?

!ommunica#le diseases t at may pose a pu#lic ealt emer)ency of international concern if it meets one or more of t e listed factors in @9 !F& 7@C7+d-G

! ancroid "onorr eaG "ranuloma in)uinaleG HansenHs disease +3eprosy-, infectiousG 3ymp o)ranuloma venereumG %yp ilis, infectious sta)eG and Tu#erculosis, activeC

HIV TravelRestrictions
Testing ReDuirements for "ountriesA-" From Mar' !ic oc'i, &C0C, former $#outCcom "uide Updated $u)ust ::, 96:6 $#outCcom Healt Hs Disease and !ondition content is reviewed #y t e Medical &eview Board $s t e HIV and $ID% epidemic continues worldwide, many forei)n countries are re(uirin) HIV tests prior to entryC Below you will find t e most current re(uirements and restrictions for countries I$I t rou) I!IC

/Eample
Albania 0o restrictions Algeria !iti,ens returnin) from wor' a#road and mem#ers of t e military are re(uired to ta'e an HIV testC Angola $ ne)ative HIV certificate is re(uired to o#tain a residence visa to wor'C Anguilla Forei)n nationals suspected of or 'nown to #e HIV positive ave #een refused entryC Argentina 0o restrictions on visits of less t an 7 mont sC Forei)ners sufferin) from any illness t at impairs t eir a#ility to wor' will not #e admittedC

Resources for"ountrySpecificRestrictions forHIVInfectedTravelers

&&&9hivtravel9org0
=lo al Data ase on HIV-Related Travel Restrictions 'pdated information from -E$ countries! on regulations denying entry or residency for people living &ith HIV! ased on relevant country legislation9

Travel +edicinePractice0 Assess the Health of HIV-Infected Traveler

Specifics oftravelitinerary RisAs related to type of travel ImmuniCation history HIV status0"D#!V< "D# F)**! defer travel 'se of ARVs If starting ne& regimen! &ait / months efore travel 6mphasiCe adherence despite challenges a road PacA sufficient amount in hand luggage( leave in marAed prescription ottles timing of ARV across time Cone

DR'= A:D +6DI"A< "AR6 ISS'6S

$de(uacy of supply of medications, includin) need for refri)eration and avoidance of damp places $de(uacy of medical care in destination, especially important in prolon)ed stays5consult wit I$M$T +International 'ssociation (or Medical 'ssistance To Travellers) $void if possi#le, new medication c an)es Just prior to travel

 Anti-retroviral therapy among HIV infected travelers to HaGG pilgrimage9 Ha#i# $", $#dulmumini M, Dal at MM, Ham,a M, Iliyasu "C + F Travel MedC 96:6 May5 FunG:<+7-.:<>5=:-

+6TH1DS0
In a co ort study in 0i)eria, clinically sta#le patients on $&T w o were travelin) for t e 966= to 966? HaJJ +HaJJ5pil)rims KHPL- were selected and compared wit consecutively selected Muslim patients w o were clinically sta#le and traveled to and from distances wit in t e country to access $&T +non5pil)rims K0PL-C Participants were clinically evaluated and interviewed re)ardin) t eir ad erence to $&T pre5travel and post5travel, international #order passa)e wit medications and reasons for missin) $&T dosesC Post5travel c an)e in !D@ counts and &0$5P!& viral load were measuredC *utcomes were proportion w o missed MorN: dose of $&T durin) HaJJ compared wit pre5 travel or post5travel and failure of $&T, defined as decline in !D@ cell counts or i) viral load

Results 0
T irty5one HP and 9< 0P ad similar c aracteristics and were away for +median Kran)eL- 7> days +9=5@7 days- and =@ days +9=5=@ days-, respectively +p O 6C666:-C T ose w o missed MorN : $&T doses amon) HP and 0P w ile away were :>D7: +A:C>8- and AD9< +:=CA8-, respectively wit ris' ratio +?A8 confidence interval K!IL9C<? +:C:=5>C>6-C $mon) HP, t e proportions w o missed MorN : $&T doses pre5travel and post5travel were lower t an t ose w o missed it durin) HaJJC T ose w o failed $&T amon) HP compared wit 0P were :AD7: +@=C@8- and AD9< +:=CA8-, respectively wit odds ratio +?A8 !I- @C:7 +:C:65:<C9:-C &easons for missin) $&T included for)etfulness, eE austion of supplies, sti)ma, spiritual alternatives, or disinclinationG five patients were una#le to cross airports wit medicationsC Patients w o went on HaJJ were more li'ely to miss medications and to ave $&T failure due to several reasons includin) ina#ility to cross #orders wit medicationsC

"onclusion 0

Travel Vaccines

V$!!I0/ U%$"/
%afety and efficacy of vaccines. 0o increased incidence of adverse reactions to inactivated vaccines as #een noted in t ese personsC However, administration of live or)anism vaccines may carry increased ris's of adverse reactions +especially polio and BF %uccessful immune response is reduced in some HIV5infected persons +dependin) on t e de)ree of immunodeficiency-C Because of t eir immunodeficiency, many HIV5infected persons are at increased ris' for complications of vaccine5 preventa#le diseases $dministration of vaccines s ould #e #ac'ed up #y #e aviors to prevent infections +eC)C, avoid mos(uito #ites in yellow fever areasG avoid eEposure to measles or c ic'enpoE patients-C

1inds of vaccines
+a- 1illed +inactivated-. Haemop ilus influen,ae +Hi#-, epatitis $, inactivated polio +IPV-, ra#ies, Fapanese encep alitis +F/+#- 3ive +attenuated-. MeasleDMumpsD&u#ella +MM&-, yellow fever +c- %u#unit. epatitis B +d- Polysacc aride. pneumococcus, menin)ococcus, typ oid Vi +e- %plit anti)en. influen,a

!onclusion of Vaccine use in HIV P

Inactivated and su#unit vaccines are safe and can #e used in HIV infected patientsC 3ive vaccines are contraindicated due to t e ris' of severe adverse reactionsC For t is reason, inactivated Ailled polio vaccines are used instead of t e oral live polio vaccineC However, eEceptions occur w en t e #enefit outwei) s t e ris'C For eEample, t e measles vaccine can #e administered to paediatric patients in t e early sta)e of

Vaccine that might 4-5

Indi*a%ion

e indicated for adults 1"T )**3HS6PT )**I

I&&uno*o&pro &i,ed HI -200 . 200

Pregnan*+

&' or &'")
H*+ ,,+"r#.e%%" I$/%ue$0" **+23 He) 1 He) 2 ,e$#$go.o.."% 3oster
$ll Persons

: dose Td #ooster every :6 yrs

7 doses for female t rou) 9> yrs +6,9,> mos-

contraindicated contraindicated : dose annually

9 doses +6,@5= w's-

: or 9 doses

--) doses 9 doses +6,>5:9 mos or >5:= mos7 doses +6,:59, @5> mos: or more doses !ontraindicated $t &is' "D"

P&/V/0TI*0 *F *PP*&TU0I%TI! I0F/!TI*0

Travel, particularly to developin) countries, may carry si)nificant ris's for eEposure to opportunistic pat o)ens for HIV5infected persons, especially t ose w o are severely immunosuppressedC Hi) er ris' for food and water#orne diseaseC Do not eat raw fruits and ve)eta#les, raw or undercoo'ed seafood or meat, tap water, ice made wit tap water, unpasteuri,ed mil' and dairy products, and food and #evera)es purc ased from street vendors55may #e contaminatedC To reduce t e ris' of cryptosporidiosis and )iardiasis, avoid swallowin) water durin) swimmin) and avoid swimmin) in water t at may #e contaminated +eC)C, wit sewa)e or

Diseases Spread y ;ecal-1ral Route0 Precautions

$lways do . Bottled fluidsG#oiledwater !oo'ed ve)eta#les Fruits t at can #e peeled %ymptomatic relief.
3operamide Bismut su#salicylate Bo) urt

"haracteristics ofTDinHIV
Primarily caused#y/T/!Galso
%almonella,!ampylo#acter, % i)ella,enteroa))re)ative/CcoliGnorovirus, rotavirus

In HIV5infected.
Bacterial pat o)ens often more severe wit #acteremia !yclospora, !ryptosporidium, Isospora may lead to c ronic diarr ea re(uirin) lon)er treatment courses

Prop ylactic antimicro#ial a)ents

$)ainst travelersH diarr ea are not recommended routinely for HIV5infected persons travelin) to developin) countries If prop ylaEis is offered, fluoro(uinolones, suc as ciprofloEacin A66m) , once daily TMP5%MQ . use for P!P prop ylactic may decrease incidence of TD $ll HIV5infected travelers to developin) countries s ould carry an antimicro#ial +eC)C, ciprofloEacin A66 m) twice daily for 75 < days- wit t em to #e ta'en as empirical t erapy s ould diarr ea develop

Identify ot er area5specific ris's

"eo)rap ically focal infections t at pose i) ris' to HIV5infected persons include. visceral leis maniasis, a proto,oan infection transmitted #y t e sandfly, and several fun)al infections +eC)C, Penicillium marneffei, coccidiodomycosis, istoplasmosis-C Many tropical and developin) areas of t e world ave i) rates of

"onsiderations for+alariainHIV
&is' ofac(uirin)malariaincreasedinHIV patients C HIV associated wit increased ris' of severe malaria Malaria can worsen HIV infection

Whitworth ! et. al. "an#et 2000$ 3%&' 10%1-10%&. Kublin ! and Ste(etee ). ! *n+e#t ,i- 200&$ 193' 1-3.

Malaria ! emoprop ylactic

Despite t e o#served dru) interactions #etween c emoprop ylactic a)ents for malaria and H$$&T dru)s, no dose adJustments of eit er ave #een recommendedC Malarone is t e commonly preferred dru) for c emoprop ylaEis, t ou) meflo(uine is also fre(uently usedC : ta#let per day wit food :59 days prior to, durin) and < days after

Malaria Treatment
T e $U! of (uinidine and (uinine is increased #y ritonavirC Ruinidine +or (uinine- is usually contraindicated in patients ta'in) ritonavir #ecause of potential cumulative cardiotoEictyC Its concurrent use wit amprenavir, delaviridine or t e lopinavirDritonavir com#ination s ould #e closely monitoredC Ruinidine +or (uinine-, owever, is still reserved for t e treatment of severe malaria, mostly caused #y *las#odiu# falci$aru#, and t e maintenance dose s ould #e reduced wit t e concomitant use of ritonavirC $lternative dru)s for t e treatment of falciparum malaria include Malarone, artesunate and meflo(uineC %elf treatment is )enerally not advised

APPR1A"H T1 TH6 R6T'R:I:= HIV-P1SITIV6 TRAV6<6R

&eview dates and itinerary More a))ressive evaluation of asymptomatic patient if visit to developin) areas was prolon)ed For symptomatic patients, c ec' incu#ation periods for t e more common diseases of travelers. % ort +less t an one wee'-. usually #acterial diarr ea, !ryptosporidium, emorr a)ic fevers Medium +up to one mont -. parasites eC) C "iardia, /ntamoe#a, Malaria, or %almonella typ i, leptospirosis 3on) +more t an a mont -. Malaria, Visceral leis maniasis, viral epatitis, amoe#ic liver a#scess, %c istosomiaisis

Summary
$ssess t epatientSsoverall ealt status Discuss HIV5related travel5entry restrictions $ssess t e patientSs immuni,ation needs includin).
&e(uired +mandated- immuni,ations Destination5related +#ut optional- immuni,ations &outine immuni,ations

Provide measures for pre5 and post5eEposure c emoprop ylaEis for prevention of malaria and self5treatment of travelersS diarr ea &eview personal disease prevention strate)ies &efer to a Travel !linic

T6RI+A ?ASIH

+AT'R S'?S+A

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