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Travel Medicine and HIV Positive Traveler
Travel Medicine and HIV Positive Traveler
Tuti Parwati Merati Division of Tropical and Infectious Disease, Department of Internal Medicine, Faculty of Medicine, Udayana University, Bali
Su -Saharan Africa "ari ean "entral America Sherrard and McCarthy. South Asia Travel Medicine and Infectious Disease 2009; 7:291 29!. S6 Asia
"e#$er et. al. % Travel Med 199!; 2: &! &&.
T e purpose of t is presentation
!urrent "lo#al $ID% %ituation and HIV Infection &is' of ac(uirin) HIV infection durin) international travel $ddresses t e issues of HIV screenin) of international travelers *ffers advice to prevent HIV infection durin) international travel &ecommendation provided for medical counselin) of t e prospective traveler w o is HIV positive + on ealt precaution, prop ylactic medication and immuni,ation-
7hat is the trigger of HIV epidemic in Asia 8 Asia population 0 /9- illion
10 million 10 million Women sell sex
75 million
(2-20% adult male)
Male !"
50 million
Women married With men who had sex with CWS
Male
Female
n#ant $ Children
% 15
10 5 0 1.6 7
Sumber : Laporan Triwulan Pengidap infeksi HI dan !asus "I#$ $ep%e&'er 2008
% 50
40 )0 20 10 0 2000
%ource. Bali Healt Department
200)
2004
2005
2007
66
Percent al&ays use condom &ith clients in the 4) last &eeA )8
)4
2 <o& argaining position among seB &orAers 4lo& education! poverty5 2 High mo ility of ;S7 2 Socio-political environment 4illegality! priority of issues5 2 Issue of morality 2 <o& demand of condom use among male clients
Children
Clients wife
Clients
SW
Clients
ID
Clients wife
Children
"ountry U%$ +FloridaU%$ +Miami and 0ewar'3ondon Paris "ermany Italy %wit,erland 0et erlands !entral, /astern, %out ern $frica 4est $frica $sia 5 Pacific
HIV Positive Rate of ;S7 4%5 6 5 768 659 659 : 76 ; <= +%4 w o are IDU-
> ; ?6 @ ; 7? 6;>
Initial TravelPreparation
"hecA entryrestrictionsforHIVtravelers Travel health insurance
+edical care HospitaliCation 6vacuation
!ommunica#le diseases t at may pose a pu#lic ealt emer)ency of international concern if it meets one or more of t e listed factors in @9 !F& 7@C7+d-G
! ancroid "onorr eaG "ranuloma in)uinaleG HansenHs disease +3eprosy-, infectiousG 3ymp o)ranuloma venereumG %yp ilis, infectious sta)eG and Tu#erculosis, activeC
HIV TravelRestrictions
Testing ReDuirements for "ountriesA-" From Mar' !ic oc'i, &C0C, former $#outCcom "uide Updated $u)ust ::, 96:6 $#outCcom Healt Hs Disease and !ondition content is reviewed #y t e Medical &eview Board $s t e HIV and $ID% epidemic continues worldwide, many forei)n countries are re(uirin) HIV tests prior to entryC Below you will find t e most current re(uirements and restrictions for countries I$I t rou) I!IC
/Eample
Albania 0o restrictions Algeria !iti,ens returnin) from wor' a#road and mem#ers of t e military are re(uired to ta'e an HIV testC Angola $ ne)ative HIV certificate is re(uired to o#tain a residence visa to wor'C Anguilla Forei)n nationals suspected of or 'nown to #e HIV positive ave #een refused entryC Argentina 0o restrictions on visits of less t an 7 mont sC Forei)ners sufferin) from any illness t at impairs t eir a#ility to wor' will not #e admittedC
Anti-retroviral therapy among HIV infected travelers to HaGG pilgrimage9 Ha#i# $", $#dulmumini M, Dal at MM, Ham,a M, Iliyasu "C + F Travel MedC 96:6 May5 FunG:<+7-.:<>5=:-
+6TH1DS0
In a co ort study in 0i)eria, clinically sta#le patients on $&T w o were travelin) for t e 966= to 966? HaJJ +HaJJ5pil)rims KHPL- were selected and compared wit consecutively selected Muslim patients w o were clinically sta#le and traveled to and from distances wit in t e country to access $&T +non5pil)rims K0PL-C Participants were clinically evaluated and interviewed re)ardin) t eir ad erence to $&T pre5travel and post5travel, international #order passa)e wit medications and reasons for missin) $&T dosesC Post5travel c an)e in !D@ counts and &0$5P!& viral load were measuredC *utcomes were proportion w o missed MorN: dose of $&T durin) HaJJ compared wit pre5 travel or post5travel and failure of $&T, defined as decline in !D@ cell counts or i) viral load
Results 0
T irty5one HP and 9< 0P ad similar c aracteristics and were away for +median Kran)eL- 7> days +9=5@7 days- and =@ days +9=5=@ days-, respectively +p O 6C666:-C T ose w o missed MorN : $&T doses amon) HP and 0P w ile away were :>D7: +A:C>8- and AD9< +:=CA8-, respectively wit ris' ratio +?A8 confidence interval K!IL9C<? +:C:=5>C>6-C $mon) HP, t e proportions w o missed MorN : $&T doses pre5travel and post5travel were lower t an t ose w o missed it durin) HaJJC T ose w o failed $&T amon) HP compared wit 0P were :AD7: +@=C@8- and AD9< +:=CA8-, respectively wit odds ratio +?A8 !I- @C:7 +:C:65:<C9:-C &easons for missin) $&T included for)etfulness, eE austion of supplies, sti)ma, spiritual alternatives, or disinclinationG five patients were una#le to cross airports wit medicationsC Patients w o went on HaJJ were more li'ely to miss medications and to ave $&T failure due to several reasons includin) ina#ility to cross #orders wit medicationsC
"onclusion 0
Travel Vaccines
V$!!I0/ U%$"/
%afety and efficacy of vaccines. 0o increased incidence of adverse reactions to inactivated vaccines as #een noted in t ese personsC However, administration of live or)anism vaccines may carry increased ris's of adverse reactions +especially polio and BF %uccessful immune response is reduced in some HIV5infected persons +dependin) on t e de)ree of immunodeficiency-C Because of t eir immunodeficiency, many HIV5infected persons are at increased ris' for complications of vaccine5 preventa#le diseases $dministration of vaccines s ould #e #ac'ed up #y #e aviors to prevent infections +eC)C, avoid mos(uito #ites in yellow fever areasG avoid eEposure to measles or c ic'enpoE patients-C
1inds of vaccines
+a- 1illed +inactivated-. Haemop ilus influen,ae +Hi#-, epatitis $, inactivated polio +IPV-, ra#ies, Fapanese encep alitis +F/+#- 3ive +attenuated-. MeasleDMumpsD&u#ella +MM&-, yellow fever +c- %u#unit. epatitis B +d- Polysacc aride. pneumococcus, menin)ococcus, typ oid Vi +e- %plit anti)en. influen,a
Pregnan*+
&' or &'")
H*+ ,,+"r#.e%%" I$/%ue$0" **+23 He) 1 He) 2 ,e$#$go.o.."% 3oster
$ll Persons
: or 9 doses
--) doses 9 doses +6,>5:9 mos or >5:= mos7 doses +6,:59, @5> mos: or more doses !ontraindicated $t &is' "D"
"haracteristics ofTDinHIV
Primarily caused#y/T/!Galso
%almonella,!ampylo#acter, % i)ella,enteroa))re)ative/CcoliGnorovirus, rotavirus
In HIV5infected.
Bacterial pat o)ens often more severe wit #acteremia !yclospora, !ryptosporidium, Isospora may lead to c ronic diarr ea re(uirin) lon)er treatment courses
"onsiderations for+alariainHIV
&is' ofac(uirin)malariaincreasedinHIV patients C HIV associated wit increased ris' of severe malaria Malaria can worsen HIV infection
Whitworth ! et. al. "an#et 2000$ 3%&' 10%1-10%&. Kublin ! and Ste(etee ). ! *n+e#t ,i- 200&$ 193' 1-3.
Malaria Treatment
T e $U! of (uinidine and (uinine is increased #y ritonavirC Ruinidine +or (uinine- is usually contraindicated in patients ta'in) ritonavir #ecause of potential cumulative cardiotoEictyC Its concurrent use wit amprenavir, delaviridine or t e lopinavirDritonavir com#ination s ould #e closely monitoredC Ruinidine +or (uinine-, owever, is still reserved for t e treatment of severe malaria, mostly caused #y *las#odiu# falci$aru#, and t e maintenance dose s ould #e reduced wit t e concomitant use of ritonavirC $lternative dru)s for t e treatment of falciparum malaria include Malarone, artesunate and meflo(uineC %elf treatment is )enerally not advised
Summary
$ssess t epatientSsoverall ealt status Discuss HIV5related travel5entry restrictions $ssess t e patientSs immuni,ation needs includin).
&e(uired +mandated- immuni,ations Destination5related +#ut optional- immuni,ations &outine immuni,ations
Provide measures for pre5 and post5eEposure c emoprop ylaEis for prevention of malaria and self5treatment of travelersS diarr ea &eview personal disease prevention strate)ies &efer to a Travel !linic
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