Statement on travellers and HIV/AIDS

Canadian Medical Association Journal 1995; 152: 379-380
Health Canada, 1994
Reproduced with permission of the Minister of Supply and Services Canada, 1996

Copies of the original report (Canada Communicable Disease Report 1994; 20: 147-149) can be obtained from Eleanor Paulson, editor, CCDR, Bureau of Communicable Disease Epidemiology, Laboratory Centre for Disease Control, Tunney's Pasture, Ottawa, ON K1A 0L2.

Preparing an HIV-infected individual for international travel requires attention to a number of important issues that for the most part are similar to those faced by any immunocompromised traveller. These considerations include the following: (1) restrictions on crossing international borders, (2) vaccination requirements and their effectiveness and safety, (3) susceptibility to infections present at the destination and (4) accessibility of health care overseas and the possible need for medical evacuation home.

Restrictions on crossing international borders

At least 50 countries, particularly in Eastern Europe and the Middle East, currently restrict the entry of travellers with HIV infection or AIDS and insist on HIV-antibody testing for foreigners as a requirement for entry. These regulations apply mostly to students, workers and others applying for long-term entry permits, although in a few countries visitors staying for periods as short as 2 weeks are required to be tested. Some countries insist on HIV testing after arrival and will not accept the results of testing done elsewhere. With respect to HIV infection, a list of entry requirements for crossing international borders may be obtained from Tropical Health and Quarantine, Laboratory Centre for Disease Control, Health Canada, tel. 613 954-3236, fax 613 954-5414.

Vaccination requirements, safety and efficacy

The benefits and risks of immunization for international travel need to be carefully considered in the case of individuals infected with HIV. Live viral vaccines such as those for yellow fever, mumps, measles, rubella and typhoid (oral vaccine) may be given to asymptomatic HIV-infected individuals with normal lymphocyte counts if they are at risk for the disease but should be avoided in patients with AIDS or low lymphocyte counts. If a specific vaccine such as the live viral vaccine for yellow fever is required for entry into a country, a medical exemption from immunization may be given. However, in high-risk situations a live vaccine may still be indicated. It should be noted that the effectiveness of vaccination may be reduced in HIV-infected individuals, especially those with AIDS. Other means of protection against infection, such as the use of insect repellents and very strict food and water precautions, should always be vigorously employed. If health risks cannot be reduced to acceptable levels, alterations in the travel plan may be necessary.

Susceptibility to infection

Many infections encountered by travellers are associated with increased morbidity and mortality in HIV-infected persons. These individuals are also more likely to have adverse reactions to drugs used to treat infection.

Gastrointestinal pathogens pose the greatest threat to HIV-infected travellers. Achlorhydria, common in patients with AIDS, allows a smaller inoculum of ingested enteric organisms to establish disease. Although enterotoxigenic Escherichia coli is the most commonly identified cause of travellers' diarrhea, it does not appear to cause more severe infection in immunocompromised hosts. Shigella, Salmonella, Campylobacter, Cryptosporidium and Isospora infections are associated with more severe and persistent diarrheal illness in HIV-infected persons. In addition, disseminated infection is well documented in salmonellosis. Because of the increased risk of infection and morbidity from bacterial pathogens, continuous antibiotic prophylaxis for travellers' diarrhea should be considered for HIV-infected persons travelling for short periods (less than 3 weeks).

Respiratory infections, most notably tuberculosis, are a threat to HIV-infected persons. Tuberculosis is a low risk for the short-term traveller; the risk increases with the duration of travel. Although morbidity from influenza itself does not increase, bacterial infections that complicate influenza are more severe in HIV-infected persons. Measles, another vaccine-preventable disease, may be severe and occasionally fatal in an HIV-infected person. Progressive, disseminated infection may follow primary exposure to people with histoplasmosis or coccidioidomycosis during travel to endemic areas.

Several vector-borne diseases may be associated with more severe illness in HIV-infected individuals. Recent reports describe visceral leishmaniasis and Chagas' disease as new opportunistic infections in AIDS patients. Theoretically, babesiosis and yellow fever are likely to be more severe in an immunocompromised host. Although malaria is the greatest vector-borne threat to the traveller, it does not appear to be more severe in the HIV-infected person.

Access to health care

If the health of an HIV-infected person should deteriorate while he or she is abroad, intensive medical interventions and even evacuation may be necessary. Not only are these expensive undertakings, but accessing high-quality, specialized medical care in many foreign countries may not be possible. Where medical evacuation is a possibility, the HIV-infected traveller should purchase medical insurance before departure to cover such an eventuality. The patient should be urged to obtain prompt evaluation of symptoms and early treatment of infection. Where possible, a physician knowledgeable about HIV infection should be identified at the point of destination before departure.

The most important question for the HIV-infected person who wishes to travel is "Do the benefits of travel exceed the risks?" This must be a personal, informed decision that must be reached carefully with the help of a health care professional who has knowledge of the patient's health status (including the CD4 lymphocyte count) and who can assess the risks associated with travel. A specific "prescription" for safe travel can then be designed for that particular individual and itinerary.

Source: Committee to Advise on Tropical Medicine and Travel: Dr. S. Dumas, Dr. G. Horsman, Dr. C.W.L. Jeanes, Dr. J.S. Keystone, Ms. S. Ladouceur (advisory committee secretariat officer), Dr. J.D. MacLean, Dr. D.W. MacPherson (chairman), Dr. R. Saginur, Dr. D. Scheifele (National Advisory Committee on Immunization), and Mrs. R. Wilson (Canadian Universities Service Overseas). Ex-officio members: Dr. M. Davies (Health Protection Branch [HPB], Health Canada), Dr. E. Gadd (HPB, Health Canada), Dr. H. Lobel (US Centers for Disease Control and Prevention [CDC]) Dr. S. Mohanna (Medical Services Branch, Health Canada), LCol. M.L. Tepper (Department of National Defence), and Dr. M. Tipple (CDC).

Selected reference

Wilson ME, Fordham von Reyn C, Fineberg HV: Infection in HIV-infected travelers: risks and prevention. Ann Intern Med 1991; 114: 582-592

Disclaimer

This guideline is for reference and education only and is not intended to be a substitute for the advice of an appropriate health care professional or for independent research and judgement. The CMA relies on the source of the CPG to provide updates and to notify us if the guideline becomes outdated. The CMA assumes no responsibility or liability arising from any outdated information or from any error in or omission from the guideline or from the use of any information contained in it.

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