Travelers with HIV

Introduction

With many effective antiretroviral therapy (ART) options available to treat human immunodeficiency virus (HIV), people with HIV who take their medications regularly can live long, healthy lives. When considering how to counsel a traveler with HIV, healthcare professionals should first consider a patient's HIV control and immune status. People with well-controlled HIV who are on ART and are regularly engaged in HIV care should feel comfortable traveling—many thousands do so each year. Individuals with poorly controlled HIV (i.e., viral load is not suppressed) or advanced HIV (CD4 cell count <200 cells/mm³, a history of an acquired immunodeficiency syndrome (AIDS)-defining illness without subsequent immune reconstitution, or current clinical manifestations of symptomatic HIV), particularly those who are newly diagnosed and treatment naïve, may face increased infectious disease risks when traveling. Recommend to patients with advanced HIV to delay travel if possible pending immune reconstitution and, ideally, viral suppression to minimize the risk of infectious diseases and immune reconstitution inflammatory syndrome during travel. Additionally, healthcare professionals should be aware of general considerations unique to travelers with HIV and be prepared to address them with patients.

History of HIV-related travel restrictions

Since the earliest years of the HIV epidemic, countries have implemented travel restrictions for travelers with HIV. Travel restrictions increased significantly following the approval of the first HIV antibody test, which enabled screening of travelers. In 1987, the United States added HIV to its list of "dangerous contagious diseases" and instituted a travel ban for all travelers with HIV. Disclosure of HIV status became mandatory for temporary visitors, and HIV testing was instituted for persons applying for permanent residence. This decision led to widespread protest and criticism that the decision was not supported by public health principles. In 2004, the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the International Organization for Migration released a joint statement declaring that HIV-related travel restrictions have no public health justification. Following the removal of regulatory language about travel and immigration restrictions by Congress in 2008, President Barack Obama rescinded all HIV-related travel restrictions in 2010.

Current state of HIV-related travel restrictions

Today, approximately 50 countries still require HIV testing or restrict entry, stay, or residence based on HIV status. Healthcare professionals should encourage travelers to be aware of the laws and policies in countries they plan to visit. Table 2.1.1 lists countries that may deport a traveler if that person is found to have HIV. Additional testing requirements or travel restrictions may apply for short- or long-term stays. Non-legal barriers, such as employer policies or lack of protections for the confidentiality of one's HIV status, may also affect travel. For those planning long-term stays, often classified as more than 90 days or requiring a residency or work permit, medical documentation (including HIV status) may be required prior to entry, whereas such a requirement is not common for short business or tourist stays.

For more information on entry and residence restrictions, consult these additional resources: (1) Positive Destinations and (2) UNAIDS HIV-related travel restrictions. Additionally, U.S. citizens and residents may contact the U.S. Embassy or consulate in the country of travel.

Table 2.1.1: Countries that may deport a traveler if they are found to have HIV¹

Tips for travelers with HIV

Instruct travelers to carry their HIV medications (and all other medications) in their original packaging with labels that identify the medication, dosing, and patient information. Travelers should bring at least a few extra days' supply of their HIV medications. These medications and any other necessary medical supplies should be kept in the traveler's carry-on luggage whenever possible. See the Travel Health Kits chapter, for additional information about suggested items to bring. Additionally, provide the traveler with an official letter that outlines medications prescribed and any required medical equipment. To prevent disclosure of the patient's HIV status, healthcare professionals may consider documenting that the ART regimen is prescribed for a medical condition but not specifically stating that it is for HIV treatment.

Encourage travelers to review their health insurance coverage to understand whether their policy covers medical care outside of the United States. Travelers may wish to consider supplemental travel health insurance and medical evacuation coverage. Advise travelers to carry a copy of their insurance policy card and copies of claim forms with them (see the Travel Insurance, Travel Health Insurance, and Medical Evacuation Insurance chapter and the Travelers with Chronic Illnesses chapter).

Considerations for long-term travel

When traveling for an extended period, travelers should maintain an adequate supply of HIV medications. Counsel the traveler about the importance of identifying a location at their destination where the individual can access HIV care and potentially receive medications, if needed. Healthcare professionals might also consider increasing the amount of medication in a prescription (e.g., from a 30-day to 90-day supply) in advance of extended travel. Travelers should be aware that countries may restrict the quantity of medicine imported (see Traveling with Prohibited or Restricted Medications chapter). U.S. citizens and residents may contact the U.S. country embassy or consulate in the country of travel for more information regarding medication restrictions.

Travel vaccines

For travelers with HIV, travel planning should begin several months ahead of departure to allow sufficient time for any necessary immunizations. Generally, immunizations are most effective in asymptomatic persons with undetectable viral loads and restored CD4 cell counts.

Vaccines for travelers, including those with HIV (Table 2.1.2), can generally be separated into three categories: (1) routine vaccines (e.g., measles, mumps, and rubella); (2) recommended vaccines based on travel destination and activities (e.g., Japanese encephalitis or rabies); and (3) required vaccines for entry (e.g., yellow fever). Inactivated vaccines are generally safe for people with HIV. Some live vaccines have sufficient safety data to recommend their use in people with HIV who have a CD4 cell count ≥200 cells/mm³. However, live replicating vaccines should not be given to individuals with advanced HIV. Live vaccines include the following: cholera; Ebola; live attenuated influenza; measles, mumps, rubella; mpox (ACAM-2000; however, JYNNEOS is replication-incompetent and therefore may be given to patients with HIV); typhoid (Ty21a); varicella; and yellow fever.

For some vaccines, antibody titers should be checked following vaccine administration to ensure adequate immune response (e.g., hepatitis A and B vaccines). Some vaccines have not specifically been studied in people with HIV; this information is noted in Table 2.1.2.

If a person has a contraindication to yellow fever vaccination and cannot change travel plans, provide them a medical waiver and emphasize the importance of avoiding mosquito bites (see Mosquitoes, Ticks, and Other Arthropods chapter). Refer to the Yellow Fever chapter, for information on how to complete the medical waiver. A sample waiver can be found in Appendix Template Letter 2: Yellow Fever Vaccine Waiver.

For additional details about vaccine schedules and considerations, refer to the Vaccination and Immunoprophylaxis—General Principles chapter. The annual immunization schedules, which are recommended by the Advisory Committee on Immunization Practices (ACIP) and approved by CDC, also summarize important vaccine recommendations for persons with HIV. Refer to these schedules when counseling patients with HIV on recommended vaccines.

Table 2.1.2: Immunizations for travelers with HIV

Prevention of malaria and other vector-borne pathogens

Pre-travel consultation for people with HIV should include an assessment of travel destinations and risk of exposure to malaria and other vector-borne pathogens in those locations. The risk of malaria and disease severity are increased in people with HIV. This is especially the case for people with advanced HIV. People with HIV who have a low CD4 count and HIV-infected women who are pregnant (or likely to become pregnant), regardless of CD4 count, should consider delaying travel to malaria-endemic areas. If travel cannot be deferred, use of effective malaria prophylaxis, although options are limited in pregnancy (see Pregnant Travelers chapter), and precautions to avoid mosquito bites (see Mosquitoes, Ticks, and Other Arthropods chapter) are essential.

Preventive measures when traveling to malaria-endemic areas include chemoprophylaxis (see Malaria chapter) and mosquito-avoidance measures. Healthcare professionals should be aware of potential drug interactions between malaria chemoprophylaxis and common ART regimens (Table 2.1.3). Mosquito avoidance measures include sleeping under insecticide-treated bed nets, the use of DEET (N,N-diethyl-3-methyl-benzamide)-containing repellants, and wearing clothes that cover most of the body. Mosquito-avoidance measures can also prevent exposure to arboviral diseases, including chikungunya, dengue, Japanese encephalitis, yellow fever, and Zika. Used in combination, these preventive measures are highly effective. However, any febrile traveler returning from a malaria-endemic area should be tested for malaria, even if they took chemoprophylaxis.

Table 2.1.3: Drug interactions for common travel medications and antiretroviral therapy regimens¹

Foodborne and waterborne illness

People with HIV should take appropriate precautions to avoid food- and waterborne infections (e.g., Campylobacter, Cryptosporidium, Escherichia coli, Giardia, Listeria, Salmonella, and Shigella), some of which can cause chronic or severe disease in people with advanced HIV. Instruct travelers about the importance of proper hand hygiene, including thorough handwashing with soap and water. Provide information on food and beverage precautions, such as consuming only boiled, treated, or bottled water in areas without adequate sanitation; only eating foods that are well-cooked and still hot; and avoiding unpasteurized dairy products. Antimicrobial prophylaxis to prevent bacterial enteric illness is not routinely recommended. Refer to the Food and Water Precautions for Travelers chapter, for additional information about food and water safety practices, and the Travelers' Diarrhea chapter, for standby therapy for enteric infections.

Drug interactions with HIV medications

Today's commonly used ART regimens are generally very well tolerated with fewer drug interactions compared to earlier regimens. However, healthcare professionals should be aware of and advise travelers of interactions between a patient's ART and common travel medications (see Medication and Vaccine Interactions in Travel Medicine). Table 2.1.3 describes drug interactions for common travel medications and ART regimens, including the first-line ART regimens recommended by the U.S. Department of Health and Human Services guidelines. For HIV drug-interaction questions, reference the University of Liverpool HIV Drug Interactions Checker page for more information.