55 HIV: travel

Travel, particularly to developing countries, may carry substantial risks of infection, e.g. malaria, salmonella, hepatitis viruses, and cryptosporidiosis. Infections, especially relevant for those with immunodeficiency, include leishmaniasis, Penicillium marneffei, coccidioidomycosis, histoplasmosis, and blastomycosis (the latter three are possible causes of cerebral abscesses). Many developing countries have high rates of tuberculosis.

Some countries have introduced HIV antibody testing for visitors (and demand their own test) or require a certificate of HIV antibody testing (done within 1 month of travel). Information by country is available at:  www.aids.about.com/od/legalissues/a/traveldi.htm. Specific information should be sought from relevant consulates.

Travel risk in relation to degree of immune deficiency, range of potential pathogens, and availability of medical care needs to be discussed and evaluated with the patient. Medical costs must be considered and adequate insurance arranged, recognizing HIV status and immune function. A confidential letter containing essential medical information is invaluable if help should be needed. Adequate medication (which may require refrigeration) should be supplied with written confirmation of treatment needed to prevent problems with customs. Rehydration sachets and standby therapy for GI infections and malaria may be indicated. If travel crosses time zones, either remain on UK time for taking medication for the entire trip or adjust in 1 hour steps before/during travel.

Preparation for travel should include review and updating of routine vaccinations (Table 55.1). Special precautions are required for non-European areas surrounding the Mediterranean, Africa, the Middle East, Asia, and South America (details available at  www.dh.gov.uk).

There is no ↑ incidence of adverse reactions to inactivated vaccines although their protective efficacy may be ↓. Live vaccines may carry ↑ risks of adverse reactions and in general should be avoided (except for measles).

Yellow fever vaccine is a live attenuated vaccine with uncertain safety and efficacy in HIV infection. WHO recommends immunization for asymptomatic HIV-infected people travelling to endemic areas, but there is insufficient evidence to advise those with symptomatic infection. Those who become asymptomatic with CD4 >200cells/μL following HAART may be offered immunization (evidence supports safety and efficacy). A certificate of exemption is needed for those who cannot be immunized if travel is necessary, and advice should be given on the risk and methods to avoid of mosquito bites (vector of yellow fever).

Cholera vaccine has little protective value.

Those with CD4 <250cells/μL are at ↑ risk from GI pathogens (cryptosporidiosis, salmonella, etc.). Particular care should be taken with raw fruit/vegetables, undercooked or raw seafood/meat, tapwater/ice, unpasteurized milk/dairy products, and food/beverages purchased from street vendors. Safe products include thoroughly cooked food, fruit peeled by the traveller, bottled/canned drinks (especially carbonated), hot coffee/tea, or water brought to the boil and simmered for 1 minute. If local tap water must be used, and cannot be boiled, the use of a water filtration unit with added chlorine or iodine ↑ its safety. Water-borne infections (e.g. cryptosporidiosis, giardiasis) may also result from ingesting water during recreational water activities. Therefore swimming in contaminated water (sewage, animal waste) should be avoided.

Prophylactic antimicrobials against travellers’ diarrhoea are not routinely recommended (side-effects/promotion of drug-resistant organisms) but if risk–benefit analysis favours their use, options include fluoroquinolones, e.g. ciprofloxacin 500mg daily and co-trimoxazole (trimethoprim–sulfamethoxazole) 960mg daily (resistance common in tropical areas). Antibiotics may be carried for empirical therapy if significant diarrhoea develops (e.g. ciprofloxacin 500mg twice daily for 3–7 days). Anti-peristaltic agents, e.g. loperamide, are useful (except if diarrhoea is bloody or associated with pyrexia) but should be discontinued if symptoms persist >48 hours. Seek medical advice if failure to respond, blood in the stool, pyrexia/rigors, or dehydration.

Advice should be given about other preventive measures for anticipated exposure, e.g. malaria prophylaxis and protection against arthropod vectors. Avoid direct soil and sand contact with skin by wearing shoes, protective clothing, and using towels on beaches to avoid hookworm, strongyloidosis, and cutaneous larva migrans. Avoid swimming in fresh water in areas of risk for schistosomiasis.

Recreational travel is commonly associated with sexual encounters. Newly acquired STIs, including HIV superinfection, can compromise the underlying HIV infection. A supply of condoms should be carried, as availability at the destination may be limited and of dubious quality.