Chapter 3Infectious Diseases Related To Travel
John T. Brooks
HIV, a single-stranded, positive-sense, enveloped RNA virus in the genus Lentivirus.
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 from mother to child during pregnancy, at birth, and postpartum through breastfeeding. HIV may be transmitted occupationally to health care workers who are exposed to blood and other potentially infectious bodily fluids via percutaneous injury or splash exposures to mucous membranes or nonintact skin (see Chapter 2, Occupational Exposure to HIV). HIV is not transmitted through casual person-to-person contact; air, food, or water; 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 people with HIV infection does not pose a risk of HIV infection for the crew members or other travelers.
HIV infection occurs worldwide. As of the end of 2010, an estimated 34 million people were living with HIV infection. Although sub-Saharan Africa remains the most affected part of the world (24.8 million cases or 68% of all people living with HIV infection), notable increases in HIV infection have occurred in Eastern Europe and Central Asia, where the number of people living with HIV infection from 2001 to 2010 rose 250% (Map 3-07). Most new infections come from low- and middle-income countries. Many countries lack comprehensive surveillance systems and, despite improvements, the true number of cases may be 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. Travelers who might undergo medical procedures, whether scheduled or in an emergency, should be aware that in developing countries the blood supply (and organs and tissues used for transplantation) might not be adequately screened, increasing the risk of HIV transmission.
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 (mean, 25 days). Ninety-seven percent of people develop antibodies in the first 3 months after infection. In rare cases, it can take up to 6 months to develop antibodies to HIV. After infection, a person remains antibody positive for life, except when people lose the capacity to mount detectable antibodies in the latest stages of the disease. The earliest time after exposure that HIV infection can be diagnosed is about 9 days, when HIV RNA becomes detectable in blood; however, the tests needed to measure HIV RNA are costly and may not be available. Any person not known to be HIV-infected who is diagnosed with an AIDS-compatible illness, such as Pneumocystis pneumonia, should be tested for HIV. For further information on HIV testing, travelers should talk to their health care provider or identify an HIV testing site near them by visiting the National HIV Testing Resources website at www.hivtest.org or call CDC-INFO toll-free at 800-CDC-INFO (800-232-4636) or 888-232-6348 (TTY). Both these resources are confidential.
Prompt medical care and effective treatment with antiretrovirals can inhibit HIV from damaging the immune system and delay progression of disease. US guidelines recommend all people with HIV infection be treated for their own health and to prevent transmission to others. 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 toll-free at 800-448-0440 (English or Spanish) or 888-480-3739 (TTY).
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.
- Work in a health care setting. Typically, exposures occur as a result of percutaneous exposure to contaminated sharps, including needles, lancets, scalpels, and broken glass (from capillary or test tubes). See Chapter 2, Occupational Exposure 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.
- Ensure that if traveling for purposes of medical treatment (“medical tourism”), the blood and blood products used in the facility where the traveler will be treated are screened for HIV and that such facilities exercise proper infection control practices.
- Consider, particularly if at high risk for acquiring HIV infection (such as men who have sex with men) discussing preexposure prophylaxis with a health care provider (see www.cdc.gov/hiv/prep).
People who are sensitive to latex should use condoms made of polyurethane or other synthetic materials and should carry their own supply of male or female condoms. 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. These travelers should request documentation of the medical necessity for traveling with these items (a doctor’s letter) to avoid having them confiscated, such as 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 HIV infection through transfusion of blood or blood products has been virtually eliminated through required testing of all donated blood. Developing countries may have no formal program or may have inadequate technology for testing blood or biological products for contamination with HIV. If transfusion is necessary, the blood should be tested for HIV antibodies by trained laboratory technicians using a reliable test.
Travelers who will be working in a medical setting (such as a nurse volunteer drawing blood or medical missionary performing surgeries) may have contact with HIV-infected or potentially infected biological materials. These travelers 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 should also become familiar with the principles of postexposure prophylaxis (note: this treatment must be initiated within 72 hours after exposure), establish a plan for seeking medical consultation, and bring a supply of antiretroviral medication sufficient to provide postexposure prophylaxis until medical care can be obtained. For more information, see Chapter 2, Occupational Exposure to HIV.
People who have been exposed to HIV in a nonoccupational setting should seek immediate medical consultation to consider postexposure prophylaxis. Postexposure prophylaxis for potential exposure to HIV as a result of 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 toll-free 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 review 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 website: www.cdc.gov/hiv
- 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 (UNAIDS). UNAIDS World AIDS Day report, 2012. Geneva: Joint United Nations Programme on HIV/AIDS (UNAIDS); 2012 [cited 2012 Dec 20]. Available from: http://www.unaids.org/en/resources/campaigns/20121120_globalreport2012/.
- 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.
- Rice B, Gilbart VL, Lawrence J, Smith R, Kall M, Delpech V. Safe travels? HIV transmission among Britons travelling abroad. HIV Med. 2012 May;13(5):315–7.
- Smith DK, Grohskopf LA, Black RJ, Auerbach JD, Veronese F, Struble KA, et al. Antiretroviral postexposure prophylaxis after sexual, injection-drug use, or other nonoccupational exposure to HIV in the United States: recommendations from the US Department of Health and Human Services. MMWR Recomm Rep. 2005 Jan 21;54(RR-2):1–20.
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TTY: (888) 232-6348
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Before you travel make sure you speak with your doctor.