HIV-infected Travelers Research Articles

Characteristics of HIV infected individuals traveling abroad. Results from the +REDIVI Collaborative Network

IntroductionThe improvement in the prognosis of HIV infection, coupled with the increase in international travel and migration, has led to a rising number of HIV infected travelers. The objective of this study was to describe the epidemiological and clinical features of returning travelers, according to their HIV status. MethodsAn observational prospective study was conducted including travelers and immigrants who traveled to visit friends and relatives (VFRs) registered in the +REDIVI collaborative network (January-2009; October-2014). +REDIVI is a national network that registers information regarding infections imported by travelers and immigrants at 21 different centers using a standardized protocol. ResultsA total of 3464 travellers were identified: 72 were HIV+ (2.1%) and 3.392 HIV− (98%). HIV+ vs. HIV− travelers were often older (40.5y vs. 34.2y P=.001), VFRs (79.1% vs. 44.4%; P<.001), and consulted less for pre-travel advice (27% vs. 37%; P=.078). The main destinations for both groups were sub-Saharan Africa and Latin America. The most frequent reasons for consultation after travel were fever, request for a health examination, gastrointestinal complaints, and abnormal laboratory tests (mainly eosinophilia and anemia), which differed between groups. The most frequent diagnoses in HIV+ travelers were malaria (38.8%), newly diagnosed HIV infection (25%), and intestinal parasites (19.4%), while for HIV− travelers the main diagnoses were “healthy” (17.9%), malaria (14%), and intestinal parasites (17.3%). ConclusionsThe typical profile of an HIV+ traveler in +REDIVI was that of a VFR traveler who did not seek pre-travel advice and made high-risk trips. This may increase the chance of acquiring travel-related infections which may pose a special risk for HIV-infected travelers. The post-travel visit was a good opportunity for HIV infection screening.

Trends and characteristics among HIV-infected and diabetic travelers seeking pre-travel advice

The number of individuals with a chronic disease increases. Better treatment options have improved chronic patients' quality of life, likely increasing their motivation for travel. This may have resulted in a change in the number of HIV-infected travelers and/or travelers with Diabetes Mellitus (DM) visiting our travel clinic. We retrospectively analyzed the database of the travel clinic of the Public Health Service Amsterdam, between January 2001 and December 2011 and examined the records for patients with these conditions. Of the 25,000 travelers who consult our clinic annually, the proportion of travelers with HIV or DM has increased significantly. A total of 564 HIV-infected travelers visited our clinic. The mean age was 41 years, 86% were male, 43% visited a yellow fever endemic country and 46.5% had a CD4 count <500 cells/mm(3). Travelers with low CD4 counts traveled significantly more often to visit friends or relatives. A total of 3704 diabetics visited our clinic. The mean age was 55 years, 52% were male, 27% visited a yellow fever endemic country and 36% were insulin-dependent. Insulin-dependent diabetics traveled more often for work than non-insulin-dependent diabetics. Adequately trained and qualified travel health professionals and up-to-date guidelines for travelers with chronic diseases are of increasing importance.

HIV Infection Among Persons Born Outside the United States

IMMIGRATION OF PERSONS TO THE UNITED STATES FROM different parts of the world brings health challenges, including infectious diseases such as tuberculosis, hepatitis B, and Chagas disease. In 2011, the incidence of tuberculosis (new infection or reactivation of latent infection) among persons born outside the United States was 12 times greater than among persons born in the United States. The prevalence of hepatitis B infection is at least 10 times higher among those born outside but living in the United States than among those born in the United States. An estimated 300 000 persons born in Latin America and living in the United States are infected with Trypanosoma cruzi, the causative parasite of Chagas disease, with less than 10 cases of new infection occurring in the United States since 1955. In this issue of JAMA, Prosser and colleagues provide data on human immunodeficiency virus (HIV) infection among persons living in but born outside of the United States. Using data from 46 states and 5 US territories reported through the HIV Surveillance System from 2007 through 2010, the authors identified 191 697 persons who were diagnosed with HIV and for whom a country or continent of birth was reported. The authors report that of these persons diagnosed with HIV infection, 30 995 (16.2%) infections occurred among those born outside the United States, and the countries of birth origin with the highest number of persons diagnosed with HIV were Mexico, Haiti, Cuba, and El Salvador. Moreover, the 4 states with the highest proportion of persons born outside the United States and diagnosed with HIV (California, Florida, New York, and Texas) were also the 4 states with the highest numbers of HIV cases reported overall. These findings demonstrate that the epidemiology of HIV among those born outside the United States is different and more complicated than is the case for other infectious diseases, such as tuberculosis, hepatitis B, or Chagas disease. For these infections, the substantially higher prevalence of infection among those born outside the United States is primarily due to high prevalence of these infections in the immigrants’ countries of origin; however, with the exception of Africa, this is not necessarily so with HIV. For example, Prosser et al report that the largest proportion of HIV diagnoses among those born outside the United States was among those from Central America (including Mexico; 41.0%) where HIV is not highly prevalent. The estimated adult HIV prevalence in Mexico is half (0.3) that of the United States (0.6). Although selective migration of HIV-infected persons from these other countries to the United States cannot be excluded, it is likely that the majority of those who immigrated from Mexico and other areas of the world where HIV infection is uncommon among adults, such as South and Southeast Asia (0.3) and east Asia (0.1%), acquired their infections in the United States. In contrast, it is likely that a higher proportion of HIV infections among those of Caribbean descent, for whom the adult prevalence of infection is 1.0%, may have occurred in the country of birth. The prevalence of HIV among those born outside the United States also may be more likely to reflect poverty than country of origin. The US National HIV Surveillance System does not capture good data on income. However, a study of heterosexuals living in poverty areas in 23 US cities found that the seroprevalence rate was more than 20 times higher among those living in impoverished areas than the prevalence rate among heterosexuals in the United States overall. It is possible that if Prosser et al would have adjusted their data for socioeconomic status, they might have found a smaller percentage of HIV infections among those born outside than among those born within the United States. Even though HIV poses no risk of casual transmission, the United States has had a very restrictive policy toward entry of persons with HIV. In 1987, the United States prohibited entry of HIV-infected travelers or legal residents. In 1991, the ban was lifted for travelers but remained in place until 2010 for those wishing to reside in the United States. During this time, the United States did not ban persons with

Pre-travel health advice for human immunodeficiency virus-infected travelers, from Rio de Janeiro

Counseling for human immunodeficiency virus infected travelers is becoming increasingly specialized. Previous studies have reported the experience of HIV-infected travelers from temperate-climate countries but little is known about HIV-infected travelers from tropical countries. A retrospective study was conducted on HIV-infected travelers presenting at a travel health clinic in Rio de Janeiro. Eleven journeys by ten people were recorded. Brazil (Amazon region and Northeast) was the destination for six journeys. Other destinations were Peru, Angola, Europe and Asia. Nine attendees were undergoing antiretroviral therapy. Few HIV-infected people from Rio de Janeiro consulted a travel medicine specialist before traveling. Since they travel to destinations in Brazil and abroad where there are endemic diseases not encountered in Rio de Janeiro, careful pre-travel planning needs to be undertaken. Strategies for increasing the frequency of pre-travel consultations need to be developed, such as closer collaboration between HIV clinics and travel health clinics.

The Travel and Tropical Medicine Manual, 4th Edition

Like the previous editions of The Travel and Tropical Medicine Manual, the 4th edition continues to successfully teach the fundamentals of travel and tropical medicine and serve as a useful reference. The manual is well-organized and literally (measuring 12 × 20 cm) and figuratively handy. It has many appealing tables and figures, a colorful cover, and a reasonable price. It remains appropriately titled, with some chapters written from a travel perspective and others from a tropical medicine perspective. The manual contains 45 chapters divided into 7 sections (Pre-Travel Advice, Advice for Special Travelers, Fever, Diarrhea, Skin Lesions, Sexually Transmitted Diseases, and Worms). The current edition has a new coeditor (Christopher A. Sanford) and new chapters on urban medicine and health advice for long-term expatriates. Its audience should continue to be primary care providers who routinely counsel patients on travel-related issues, infectious disease physicians with an interest in travel medicine, other travel medicine practitioners, and trainees doing rotations in travel medicine. However, its technical terminology and concepts prevent the manual from achieving its stated goal of being a “perfect source” for travelers. The greatest strengths of the manual continue to be its practical suggestions for counseling travelers prior to their departure and evaluating patients with post-travel illnesses. Notable chapters discuss general approaches to travel medicine, immunizations, managing jet lag and motion sickness, counseling HIV-infected travelers, malaria prevention, avoiding and self-treating travelers’ diarrhea, evaluating diarrhea in returned travelers, tropical dermatology and sexually transmitted infections. The manual also has outstanding tables in its approach to travel medicine chapter. Other informative tables describe the safe selection of food and water, drugs for preventing and treating traveler’s diarrhea, the use of melatonin to prevent jet lag, potential interactions between antiretroviral and travel-related medications, and the differential diagnoses of travel-related skin lesions. The manual wisely refers readers to internet sites such as www.cdc.gov/travel for up-to-date travel advice. Although the manual has shortcomings, it has no serious deficiencies. Incorporating contributions from 49 authors results in chapters of variable quality, some redundancies, and occasional omissions. A 20-page chapter on water disinfection appears disproportionately lengthy when compared with the immediately preceding 12-page chapter on the prevention and self-treatment of traveler’s diarrhea. Although the chapter on women travelers discusses male condoms superficially, this important topic is well addressed in the chapter on sexually transmitted infections. In future editions of the manual, the editors should consider including more than 2 photographs in the 74-page section on skin lesions, using a larger font, and enlarging the figures. Clinicians who routinely evaluate patients before or after traveling should definitely consider purchasing this manual, reading select chapters in the pretravel and special travelers sections, and keeping it in their travel clinic as a useful reference.

Fever After a Stay in the Tropics: Clinical Spectrum and Outcome in HIV-Infected Travelers and Migrants

To investigate the epidemiology and clinical spectrum of fever in HIV-infected returning travelers and migrants. From April 2000 to December 2006, we explored prospectively, at our referral travel/HIV clinics, the etiology and outcome of febrile illnesses developing within 3 months after a stay in the tropics. For this study, we compared the morbidity profile between HIV-infected individuals and all other cases tested HIV negative. Of the 1850 adults (15 years and older) evaluated for 1921 fever episodes, 93 (5%) had HIV infection, including 5 presenting with primary infection. HIV prevalence was 2% in western travelers or expatriates, 11% in travelers "visiting friends and relatives," and 24% in foreign visitors/migrants. Fever episodes (n = 104) occurring in the HIV-infected individuals were mainly due to opportunistic infections (23%, including tuberculosis), respiratory tract infections (20%), sexually transmitted infections (9%), and noninfectious diseases (7%). All these conditions were more frequently diagnosed than in HIV-negative travelers (1035 fever episodes), although tropical infections (mostly malaria) were proportionally less prevalent. Morbidity (rate and duration of hospitalization) was more considerable in HIV-infected patients than in HIV-negative individuals. HIV infection was frequent in returning travelers and migrants presenting with fever at our setting and affected strongly the diagnostic spectrum and overall morbidity.

Microsporidiosis in travelers with diarrhea from the tropics.

Microsporidia are protozoa which mainly affect severely immunodepressed AIDS patients in developed countries as well as those in developing ones. Traveler's diarrhea affects approximately 40% of people traveling from industrialized countries to developing ones, and no pathogens are identified in many of those patients on their returning, suggesting that known enteropathogens escape detection or entirely new ones could be responsible. Very few reports of travel-related microsporidiosis have been described. Between January, 1996 and January, 1998, a total of 40 European travelers from the tropics with a clinical picture of protected diarrhea (three or more loose stools per day lasting for more than 3 weeks) were evaluated. Weber's trichrome modified by Kokoskin stain for microsporidial spores were performed in stool samples of every patient. Microsporidial DNA extraction and PCR amplification were attempted in every stool sample where microsporidial spores were observed. Four cases of imported Enterocytozoon bieneusi were detected: one HIV-infected short term traveler, a pregnant long term traveler, and two immunocompetent short term travelers. Diarrhea was self-limited, and the spores cleared from the stools in all HIV-non infected travelers, but showed a chronic course in the HIV-infected one. Available data is too limited to affirm that residence or travel in tropical countries increases the risk for microsporidial infection, but the cases presented here suggest that E. bieneusi could be a cause of self-limited diarrhea in immunocompetent travelers returning from the tropics or could chronically affect immunocompromised HIV-infected travelers.

Common health problems in HIV-infected travelers to the (sub)tropics.

A study was conducted to estimate the incidence of health problems in HIV-infected travelers with various degrees of immunodeficiency to the (sub)tropics. A retrospective questionnaire-based study among HIV-infected patients attending the outpatient department of a university hospital during three months in 1996 with a history of travel to (sub)tropical destinations in the proceeding 12 months. The outcome measures were incidences of and medical consultation rates for common travel-associated illnesses. Of 293 HIV-infected patients, 59 (20%) had traveled during the preceding 12 months; of these 36 (61%) responded. Ten (28%) had traveled more than once during this period. There were no significant differences between travelers and nontravelers regarding CD4 count and age. Fifteen respondents (42%) used cotrimoxazole (CTX) for PCP prophylaxis; 22 (61%) had sought pretravel health advice. Median duration of travel was 3 weeks. Respiratory infections were recorded by two respondents (6%, 95% confidence intervals 1-19%) and skin problems by 10 (28%, 14-45%). Of 31 respondents without diarrhea on departure, 10 recorded diarrhea (32%, 19-57%). The overall rate of medical consultation for travel-related complaints ws 5% abroad and 28% after return, respectively. There was no association between the risk of diarrhea and CD4 count or CTX prophylaxis, even after adjustment for differences in age, duration of travel and travel experience. Although numbers in this study are small, HIV-infected travelers tend to have a high rate of medical consultation for (possibly) travel-related illness. Diarrhea is the most frequent complaint, but shows no strong association with degree of immunodeficiency.

Infections in HIV-infected Travelers: Risks and Prevention

To review risks for infection and to outline strategies to protect the health of travelers infected with human immunodeficiency virus (HIV). Original reports and summaries of the geographic distribution and frequency of infections as well as of special risks these infections impose on HIV-infected persons. The recommendations incorporate guidelines published by the Centers for Disease Control (CDC) and the World Health Organization. Sources containing the most recent, pertinent information. Infections of the gastrointestinal tract are common in all travelers to developing countries and are likely to be more frequent, severe, and difficult to treat in HIV-infected persons. Prominent among the respiratory tract infections that pose special risks to HIV-infected travelers are influenza, measles, and fungal infections with geographically focal distributions. The most common vector-borne infection, malaria, appears to present relatively little, if any, incremental risk to the HIV-infected traveler. Persons with HIV infection respond less vigorously to vaccines and have a higher frequency of adverse reactions to antimicrobial agents. Nevertheless, immunizations and chemoprophylaxis can reduce the risk for many travel-related infections. Additionally, there are protective measures that travelers can take to minimize exposure to pathogens. By understanding the risks for disease in different destinations, assessing patients' HIV status, counseling patients about travel plans and personal protective measures, appropriately using vaccines and chemoprophylaxis, as well as instituting early treatment of infection, physicians can help HIV-infected patients to preserve their health during travel.