Chapter 3Infectious Diseases Related To Travel
HIV & AIDS
John T. Brooks
Acquired Immunodeficiency Syndrome (AIDS) is a serious disease that represents the late clinical stage of infection with human immunodeficiency virus (HIV). HIV progressively damages the immune system. Without an effective immune system, life-threatening infections and other noninfectious conditions related to failing immunity (such as certain cancers) eventually develop.
MODE OF TRANSMISSION
HIV can be transmitted through sexual contact, needle- or syringe-sharing, medical use of blood or blood components, organ or tissue transplantation, and artificial insemination; it can also be transmitted perinatally from an infected woman to her infant. HIV is not transmitted through casual contact; air, food, or water routes; contact with inanimate objects; or by mosquitoes or other arthropod vectors. The use of any public conveyance (such as airplanes, automobiles, boats, buses, or trains) by individuals with AIDS or HIV infection does not pose a risk of HIV infection for the crew members or other travelers.
AIDS and HIV infection occur worldwide. At of the end of 2008, more than 33 million people were living with HIV/AIDS. Although sub-Saharan Africa remains the most affected part of the world (22.4 million cases), notable increases in HIV infection have occurred from 2001 to 2008 in Eastern Europe and throughout Asia (Map 3-07). Ninety-seven percent of new infections come from low- and middle-income countries. Many countries lack comprehensive surveillance systems, and despite improvements, the true number of cases is likely higher than officially reported, particularly in developing countries.
The risk of HIV infection for international travelers is generally low, although the risk is determined less by geographic destination and more by behaviors such as drug use and unprotected sex. In developing countries, the blood supply might not be adequately screened, increasing the risk of HIV transmission by transfusion.
Any person who suspects that she or he may have been exposed to HIV should be tested. Most people develop detectable antibodies within 2–8 weeks (the average is 25 days). Ninety-seven percent of people develop antibodies in the first 3 months after infection. In very rare cases, it can take up to 6 months to develop antibodies to HIV. The time from the onset of HIV infection and a positive RNA test is about 9 days; however, these tests are costly and may not be available. Diagnosis of HIV infection and AIDS may also be made when a patient presents with an AIDS-compatible diagnosis, such as Pneumocystis pneumonia, and is subsequently found to be HIV-seropositive. For information on HIV testing, travelers should talk to their health care provider or identify the location of an HIV testing site near them by visiting the National HIV Testing Resources website at www.hivtest.org or call CDC-INFO at 800-CDC-INFO (800-232-4636) or 888-232-6348 (TTY), in English or Spanish. Both these resources are confidential.
Prompt medical care may delay the onset of AIDS and prevent some life-threatening conditions. Detailed information on specific treatments is available from the Department of Health and Human Services AIDSinfo: www.aidsinfo.nih.gov. Information on enrolling in clinical trials is also available at AIDSinfo. Travelers may contact AIDSinfo by phone, 800-448-0440 (English or Spanish) or 888-480-3739 (TTY).
PREVENTIVE MEASURES FOR TRAVELERS
No vaccine is available to prevent infection with HIV. Travelers should be advised that they are at risk if they:
- Have sexual contact (heterosexual or homosexual) with an infected person.
- Use or allow the use of contaminated, unsterilized syringes or needles for any injections or other procedures that pierce the skin, including acupuncture, use of illicit drugs, steroid or vitamin injections, medical or dental procedures, ear or body piercing, or tattooing.
- Receive infected blood, blood components, or clotting factor concentrates. HIV infection by this route is rare in countries or cities where donated blood and plasma are screened for antibodies to HIV.
To reduce their risk of acquiring HIV, travelers should:
- Avoid sexual encounters with people who are infected with HIV, whose HIV infection status is unknown, or who are at high risk for HIV infection, such as intravenous drug users, commercial sex workers (both male and female), and other people with multiple sexual partners.
- Use condoms consistently and correctly, especially if engaging in vaginal, anal, or oral-genital sexual contact with a person who is HIV infected or whose HIV status is unknown.
- Avoid injecting drugs.
- Avoid sharing needles or other devices that can puncture skin.
- Avoid, if at all possible, blood transfusions or use of clotting factor concentrates.
People who are sensitive to latex should use condoms made of polyurethane or other synthetic materials and should carry their own supply of condoms. When a male condom cannot be used properly, a female condom should be considered. If no condom is available, travelers should abstain from sex with people who are HIV infected or whose HIV status is unknown. Barrier methods other than condoms do not prevent HIV transmission. Spermicides alone are also not effective. The widely used spermicide nonoxynol-9 can increase the risk of HIV transmission and should not be used.
Needles used to draw blood or administer injections should be sterile, single use, disposable, and prepackaged in a sealed container. If at all possible, travelers should avoid receiving medications from multidose vials, which may have become contaminated by used needles. Travelers with type 1 diabetes, hemophilia, or other conditions that necessitate routine or frequent injections should be advised to carry a supply of medication, syringes, needles, and disinfectant swabs sufficient to last their entire stay abroad. Before traveling, these travelers should consider requesting documentation of the medical necessity for traveling with these items (a doctor’s letter) in case their need is questioned by inspection personnel at ports of entry (see Chapter 2, Travel Health Kits, for more information about traveling with medications).
In many developed countries, the risk of transfusion-associated HIV infection has been virtually eliminated through required testing of all donated blood. Developing countries may have no formal program, or inadequate technology, for testing blood or biological products for contamination with HIV. If transfusion is necessary, the blood should be tested for HIV antibody by trained laboratory technicians using a reliable test.
People who in the course of their travel (such as a nurse volunteer drawing blood or medical missionary performing surgeries) may have contact with HIV-infected or potentially infected biological materials should ensure that they will have access to all personal protective equipment necessary (latex gloves, goggles, face shield, gowns) and that this equipment meets established international quality standards. Such travelers may also wish to consider familiarizing themselves with the principles of postexposure prophylaxis, establish a plan for seeking medical consultation, and bring a supply of antiretroviral medication of sufficient quantity to provide postexposure prophylaxis until medical care can be obtained. For more information, see Chapter 2, Occupational Exposure to HIV.
The efficacy of postexposure prophylaxis with antiretrovirals for nonoccupational exposures to HIV (such as sex or injection drug use) has not been established. It may be considered an unproven clinical intervention, after careful consideration of potential risks and benefits and with full awareness of gaps in current knowledge. Postexposure prophylaxis for potential exposure to HIV resulting from mass-casualty events is generally not warranted, except in special circumstances (for example, a blast injury in a facility that contained a large archive of HIV-infected blood specimens). Clinicians seeking advice on postexposure prophylaxis can call the US National HIV/AIDS Clinicians’ Consultation Center PEPline at 888-448-4911 (www.nccc.ucsf.edu).
HIV TESTING REQUIREMENTS FOR US TRAVELERS ENTERING FOREIGN COUNTRIES
International travelers should be advised that some countries screen incoming travelers for HIV infection and may deny entry to people with AIDS or evidence of HIV infection. These countries usually screen only people planning extended visits, such as for work or study. People intending to visit a country for an extended stay should be informed of that country’s policies and requirements. This information is usually available from the consular officials of the individual nations. Information about entry and exit requirements compiled by the Department of State can be found at http://travel.state.gov/travel/tips/tips_1232.html#requirement.
- CDC. HIV prevention bulletin: medical advice for persons who inject illicit drugs. Atlanta: CDC; 1997 [updated 2009 May 8; cited 2006 May 31]. Available from: http://www.cdc.gov/idu/pubs/hiv_prev.htm.
- CDC. Management of possible sexual, injecting-drug-use, or other nonoccupational exposure to HIV, including considerations related to antiretroviral therapy. MMWR Recomm Rep. 1998 Sep 25; 47(RR-17):1–14.
- Chapman LE, Sullivent EE, Grohskopf LA, Beltrami EM, Perz JF, Kretsinger K, et al. Recommendations for postexposure interventions to prevent infection with hepatitis B virus, hepatitis C virus, or human immunodeficiency virus, and tetanus in persons wounded during bombings and other mass-casualty events—United States, 2008: recommendations of the Centers for Disease Control and Prevention (CDC). MMWR Recomm Rep. 2008 Aug 1;57(RR-6):1–21.
- Joint United Nations Programme on HIV/AIDS. 2010 report on the global AIDS epidemic. Geneva: Joint United Nations Programme on HIV/AIDS; 2010 [cited 2010 Dec 01]. Available from: www.unaids.org/globalreport.
- Memish ZA, Osoba AO. Sexually transmitted diseases and travel. Int J Antimicrob Agents. 2003 Feb;21(2):131–4.
- Panlilio AL, Cardo DM, Grohskopf LA, Heneine W, Ross CS. Updated US Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. MMWR Recomm Rep. 2005 Sep 30;54(RR-9):1–17.
- Wright ER. Travel, tourism, and HIV risk among older adults. J Acquir Immune Defic Syndr. 2003 Jun 1;33 Suppl 2:S233–7.
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