The International AIDS Society–USA

1. The HIV-Infected Traveler Merceditas Villanueva, MDAssociate Professor of MedicineYale University School of Medicine The International AIDS Society–USA From M Villanueva, MD, at New York, NY: March 22, 2010, IAS–USA.

2. Travel Medicine • Developed as own discipline over past 25 years due to growth in international travel • Represented by ISTM and ASTMH clinical groups • Focus on pre-travel preventive care(as opposed to tropical medicine which focuses on diagnosis and treatment of illness acquired during foreign travel)

3. Pre-HAART(Kemper et. al. 1992-93) Survey in hospital-based HIV clinic, California 46% had traveled within US; 20% with foreign travel within2 years Median CD4=120/mm3 Reason for travel: 30% thought last chance to travel Post-HAART(Sherrard 1997-2007) International Health Clinic, Ottawa, Canada 57% foreign born: travel to visit friends and relatives 43% Canadian born: travel for vacation and business Median CD4=440/mm3 Destinations: (in order) Sub-Saharan Africa Caribbean Central America South Asia SE Asia Demographics of International Travel in HIV-Infected Patients Sherrard and McCarthy. Travel Medicine and Infectious Disease 2009; 7:291-295. Kemper et. al. J Travel Med 1995; 2: 85-88.

4. Initial Travel Preparation • Check entry restrictions for HIV travelers • Travel health insurance • Medical care • Hospitalization • Evacuation • Obtaining medical care abroad

5. Resources for Country-Specific Restrictions for HIV-Infected Travelers • www.hivtravel.org: • Global Database on HIV-Related Travel Restrictions • Updated information from 196 countries, on regulations denying entry or residency for people living with HIV, based on relevant country legislation.

6. Specifics of travel itinerary Risks related to type of travel Immunization history HIV status: CD4, VL CD4<200, defer travel Use of ARVs If starting new regimen, wait 3 months before travel Emphasize adherence despite challenges abroad Pack sufficient amount in hand luggage; leave in marked prescription bottles Travel Medicine Practice: Assess Health of HIV-Infected Traveler

7. Travel Vaccines

8. Live Vaccines in HIV

9. Inactivated Vaccines and HIV

10. Considerations for Malaria in HIV • Risk of acquiring malaria increased in HIV patients • HIV associated with increased risk of severe malaria • Malaria can worsen HIV infection Whitworth J et. al. Lancet 2000; 356: 1051-1056. Kublin J and Steketee R. J Infect Dis 2006; 193: 1-3.

11. Anti-Malarial Options

12. Bottled fluids; boiled water Cooked vegetables Fruits that can be peeled Symptomatic relief: Loperamide Bismuth subsalicylate Yogurt Diseases Spread by Fecal Oral Route: Precautions

13. Characteristics of TD in HIV • Primarily caused by ETEC; also Salmonella, Campylobacter, Shigella, enteroaggregative E. coli; norovirus, rotavirus • In HIV-infected: • Bacterial pathogens often more severe with bacteremia • Cyclospora, Cryptosporidium, Isospora may lead to chronic diarrhea requiring longer treatment courses

14. Summary • Assess the patient’s overall health status • Discuss HIV-related travel-entry restrictions • Assess the patient’s immunization needs including: • Required (mandated) immunizations • Destination-related (but optional) immunizations • Routine immunizations • Provide measures for pre- and post-exposure chemoprophylaxis for prevention of malaria and self-treatment of travelers’ diarrhea • Review personal disease prevention strategies • Refer to Travel Clinic

15. Travel Health Resources • CDC Travelers’ Health Website • www.cdc.gov/travel • World Health Organization • www.who.int/int • State Department • travel.state.gov • International Society of Travel Medicine • www.istm.org • Health Information for International Travel • CDC “Yellow Book” • International Travel and Health • WHO “Green Book”