EMPORIATRIC MEDICINE AND THE HIV-INFECTED TRAVELER

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EMPORIATRIC MEDICINE AND THE HIV-INFECTED TRAVELER
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ISSUES FOR ALL TRAVELERS

• Generally want at least 4-6 week lead time prior
  to departure to assess travel needs, especially
  vaccines and need for malaria chemoprophylaxis
• Get list of medical clinics from IAMAT
  www.iamat.org
• Bring 30-35 DEET spray where biting insects are
  anticipated
• Avoid piercings and tatoos, acupuncture, even
  shaving by a barber in many of these developing
  areas
• Be cautious of motor vehicle travel
• Swim only in chlorinated water
• Health insurance both international
  insurance(try credit card companies, yellow
  pages, internet) and air ambulance insurance
  www.airambulancedirectory.com

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SPECIFIC PRECAUTIONS FOR ENTERITIS

• Developing countries especially important in
  patients with severe immunosuppression
• Food and waterborne diseasessame precautions for
  all travelers regardless of HIV serostatus
• If you cant boil it, peel it, cook it, then
  forget it!!
• No tap water, ice cubes. Bottled water, including
  for brushing teeth!
• Portable water purifiers ( with absolute one
  micron filter)

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TRAVELERS DIARRHEA

• If travelers diarrhea is severe must seek
  medical attention (gi bleeding, fever, vomiting,
  prostration)
• Enterotoxigenic E. coli probably no different in
  its presentation, but Salmonella, Campylobacter,
  Shigella can be worse in HIV people
• Occasional microsporidia(J Travel Med 1999
  Dec6(4)223-7), enteroaggregative E. coli(CID
  2001 Jun 1532(12)1706-9), and Cryptosporidia
• Other causes of enteritis eg,Cyclospora, Isospora
  belli, helminths, C. difficile, tropical sprue
• Treatment for uncomplicated diseasecipro 500mg
  BID for three to seven days with first day
  imodium.

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SELF-MEDICATION FOR OTHER AILMENTS

• Options of self-medication for respiratory tract
  infection, sinusitis, otitis media,UTI, cellulitis

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INTERNATIONAL SCREENING OF TRAVELERS FOR HIV
INFECTION

• Primarily aimed for those with extended stays
  work visas, students
• Approximately 50 countries may block entry of
  HIV travelers
• Check with consular office(s) or go to
  www.travelstate.gov/hivtestingreqs.html
• Our own calls to Brazilian, Canadian, and British
  consulates did not bear out any refusal to have
  HIV travelers in their nation for short-term
  stay. However, long-term stay decided on case by
  case basis.

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TIMING OF HAART ACROSS TIME ZONES

• Take more doses in the period than less.
• East to West extra dose of Nukes, viramune and
  PIs at bedtime
• West to East extra dose next morning
• Efavirenz doesnt need an extra dose (G. Moyle,
  personal comm.)
• Viread has long intracellular half-life and may
  not need an extra dose
• Debatable what to do with indinavir with respect
  to risk of nephrolithiasis

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DRUG AND MEDICAL CARE ISSUES

• Adequacy of supply of medications, including need
  for refrigeration and avoidance of damp places
• Adequacy of medical care in destination,
  especially important in prolonged stays-consult
  with IAMAT
• Avoid if possible, new medication changes just
  prior to travel

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MALARIA PREVENTION

• Same precautions and prophylaxis with all
  travelers
• Review itinerary on www.cdc.gov malaria site
• Disease presentation not different in HIV, except
  more severe in HIV-positive pregnant women
• Mosquito bite prevention with 30-35 DEET, bed
  netting, permethrin spray, and avoidance of dusk
  to dawn exposure
• Drug interactions mefloquine had variable
  effects on ritonavir, with decrease in Cmax,
  Cmin, AUC. Despite strong inhibition of CYP3A4,
  mefloquine levels were not affected by ritonavir
  (Khaliq et al, 7th Conf on Retro, abstract 92,
  2000)
• Malarone Proguanil AUC increased possibly via
  CYP 2D6, Atovaquone AUC may be decreased in
  presence of Ritonavir, mechanism unknown (Karp,
  Current Inf Dis Rep 2001, 350-8)
• Despite these observations, there are currently
  no dose adjustments recommended at this time.
• Measure patients glucose-6-phosphate
  dehydrogenase level prior to trip (possible need
  for primaquine)

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MALARIA TREATMENT

• QuinidineAUC increased by ritonavir via CYP3A4
  inhibition. Quinidine reserved for severe malaria
  and decrease in maintenance rate of drug
  required. Quinine probably increased to lesser
  extent and should be avoided (risk of prolonged
  QT interval with Torsades de pointes)
• Treat non-severe malaria with malarone 4
  pills/day for three days, or with lariam
  (increased risk of seizures).
• Self-treatment not generally advised

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VACCINE ISSUES IN HIV TRAVELER

• Potential exposure to pathogen
• Potential increase in side effects to vaccine
• Potential decreased efficacy of vaccine

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VACCINES

• In most developing areas of world, following
  vaccine-preventable illnesses are addressed
• Measles
• Hepatitis A
• Typhoid Fever
• Influenza
• Yellow fever
• Hepatitis B
• Polio
• Japanese encephalitis
• Rabies
• Cholera
• Meningococcus

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VACCINES

• Killed (inactivated) Hepatitis A, Inactivated
  Polio (IPV), Rabies, Japanese encephalitis
• Live (attenuated) MMR, Yellow fever, oral
  Typhoid
• Subunit Hepatitis B
• Polysaccharide Pneumococcal, Meningococccal,
  Typhoid Vi
• Split antigen Influenza

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MEASLES VACCINE

• Increased prevalence of disease in SE Asia,
  Africa (especially sub-Saharan) based on W.H.O.
  data on measles in children
• Worse disease with increased morbidity and
  mortality in HIV-infected people with pneumonitis
  and also encephalitis.
• Increased risk of vaccine side effects in
  severely immunosuppressed one known death in
  patient with AIDS and deaths in other
  immunosuppressed recipients.
• Vaccine considered safe in adults if T-helper
  count gt200 /or T-helper gt14
• If immune serum globulin prescribed to prevent
  Hep A, separate injections by at least two weeks
• Role of measuring serum IgG measles antibody
• Use of gammaglobulin if inadequate antibody in
  AIDS, dose suggested is 15 ml IM. IVIG may also
  be okay.

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YELLOW FEVER

• Mosquito-borne disease in tropical South America
  and Sub-Saharan Africa
• Severity of illness from flu-like illness to
  severe hepatitis and hemorrhagic fever with a
  classic biphasic illness
• Fatality rate of severe disease ranges from 20
  to 65
• Not known if HIV influences presentation of
  illness
• Asymptomatic HIV recipients of vaccine without
  adverse effects
• Lower antibody titers in HIV children
• Consider measurement of antibody titer after
  vaccination
• Vaccine not recommended in symptomatic
  HIV-positive adults, certainly not if T-helper
  count lt200.

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GLOBAL DISTRIBUTION OF YELLOW FEVER, 1996
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YELLOW FEVER

• Options to taking vaccine
• Avoiding areas of transmission altogether
• If in an area of potential exposure, meticulously
  avoiding mosquito bites
• Vaccine waiver letter-this may not be accepted at
  border. Need to arrange this with consulate prior
  to leaving USA
• Distinguish requirements of country from actual
  zones of endemicity

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HEPATITIS A

• Vaccine response is lower in HIV patients, with
  dramatically low response rate in patients with
  lt200 cells/mm3(Kemper et al, JID 2003 April 15
  187(8)1327-31)
• Know if measurable IgG prior to travel. However,
  actual protective titer against infection is
  unknown.
• Generally, if less than one month prior to
  travel, give immune serum globulin with option of
  starting Hepatitis A vaccine series at same time.
  There are no current recommendations for an
  accelerated schedule.
• Dose of immune serum globulin 0.02 ml/kg body
  weight IM for trip less than three months. If
  longer trip, give 0.06 ml/kg IM.
• Prolonged viral shedding reported in HIV
  patients with acute Hep A

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HEPATITIS B

• Know immune status prior to travel
• Risk to international travelers generally low
• Must warn susceptible patients of sexual risk of
  acquisition
• Consider extra doses of vaccine if patient a
  non-responder (Rey et al Vaccine 2000 Jan 18
  18(13)1161-5)

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MENINGOCOCCUS

• Endemic to sub-Sahara Africa during the dry
  season, occasional epidemics reported elsewhere
• Vaccine required for annual Hajj in Mecca
• Very scant information on HIV and disease. No
  mention on efficacy of vaccine in HIV infection

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JAPANESE ENCEPHALITIS

• Caused by a flavivirus, transmitted by mosquito
• Endemic to rural areas of SE Asia, varies often
  with season
• Most cases are subclinical. Symptomatic disease
  presents as an acute encephalitis--? seizures,
  paralysis, coma, death prolonged recovery in
  survivors and permanent brain injury in some
• It is a rare disease of travelers
• Killed vaccine recommended for travelers with
  prolonged stays in endemic areas
• Vaccine occasionally causes severe allergic
  reaction requiring emergent care
• One study demonstrating reduced antibody titers
  in HIV children vaccinated with JE vaccine
• Alteration in presentation of illness in
  HIV-infected people not known

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POLIO

• Most world transmission currently in south Asia
  and sub-Sahara Africa
• Only inactivated polio vaccine (IPV) available in
  the USA
• Usually give one adult dose, unless primary
  series never done or completed

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OTHER VACCINES

• Typhoid two vaccines available one live and one
  killed-use only the latter in HIV patients.
• Typhim Vi has lower antibody response rate in
  patients with less than 200 CD4 T lymphs
  (Vaccine 1999 Aug 617(23-24)2941-45)
• Influenza-year-round endemicity in the tropics
  and April - September in southern hemisphere. No
  recommendations on revaccinating prior to travel
• Diptheria/Tetanus
• Pneumococcus

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PENICILLIUM MARNEFFEI

• Fungal infection endemic to SE Asia, acquired by
  inhaling spores
• Opportunistic infection in AIDS
• Chronic illness with fever, weight loss, anemia,
  generalized lymphadenopathy, hepatomegaly,
  umbilicated papules. Other organ systems can also
  be involved.
• Diagnosisbone marrow, skin lesion, blood culture
• Treatment Ampho B, followed by itraconazole

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VISCERAL LEISHMANIASIS

• Protozoan parasite transmitted by sandflies
• 90 world cases acquired in India, Bangladesh,
  Sudan, Nepal, Brazil and also endemic in
  Mediterranean countries
• Typically a chronic illness with prolonged
  incubation period. Typically have
  hepatosplenomegaly, fevers, weight loss
• In AIDS, worse cytopenias, and atypical
  presentations pleuropulmonary, GI
• Serologic tests less sensitive in AIDS
• Lower treatment response in AIDS
• HAART and secondary prophylaxis improves survival
  

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TUBERCULOSIS

• Know PPD status prior to trip
• Repeat PPD after return, especially after
  prolonged trip.
• Risk of acquisition might be much higher in
  health care setting

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APPROACH TO THE RETURNINGHIV-POSITIVE TRAVELER

• Review dates and itinerary
• More aggressive evaluation of asymptomatic
  patient if visit to developing areas was
  prolonged
• For symptomatic patients, check incubation
  periods for the more common diseases of
  travelers
• Short (less than one week)bacterial diarrhea,
  Cryptosporidium, hemorrhagic fevers
• Medium (up to one month) Giardia, Entamoeba,
  Malaria, Salmonella typhi, leptospirosis
• Long Malaria, Visceral leishmaniasis, viral
  hepatitis, amoebic liver abscess,
  Schistosomiaisis

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EOSINOPHILIA

• May see this anyway in HIV-infected persons
• However, in setting of travel to indigenous
  areas, helminthic infections should be looked for
  in fecal smears

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SUMMARY

• Precautions generally same for HIV and non-HIV
  infected travelers
• Decisions regarding live vaccines are very
  weighted to patients immune status
• May anticipate lower response to all vaccines and
  hence increased risk of disease
• Incomplete information currently on need for dose
  or drug changes for malaria prevention in
  patients taking ritonavir
• Patients taking proper precautions and not
  severely immunocompromised should do well.
• Sometimes, travel itinerary should be modified to
  avoid potential exposures
• Differential diagnosis of illness in returning
  HIV-positive traveler can be very broad both in
  short term and long term follow-up