Preparing HIV+ Patients for Travel I have nothing to disclose Greg - - PDF document

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Preparing HIV+ Patients for Travel

Greg Melcher, M.D. Professor of Clinical Medicine Division of Infectious Diseases UCSF

Disclosures

 I have nothing to disclose

Learning Objectives

 Develop an approach to the evaluation of the

HIV+ traveler

 Understand the role of immune suppression

in modifying pre-travel vaccination recommendations

 Understand how to use various pre-travel

resources to tailor recommendations

Approach to Traveler Health

 Assessment 4-6 weeks prior to departure  Medical history  Specific itinerary  Activities  Accommodations and food plans

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HIV+ female, CD4 550

 24 yo female plans 3 month trip to Brazil  Veterinary tech  Medications: ABC/3TC/DTG, BCPs  Up to date with MMR, Prevnar-13, Pneumovax,

Tdap, Influenza, Hepatitis A & B

 Winter season, living in group camp in rural Amazon

river basin

 Food prepared in group kitchen by program staff

HIV+ female, CD4 550

http://wwwnc.cdc.gov/travel/destinations/clinician/immune_compromised.mission_disaster/brazil?s_c id=ncezid-dgmq-travel-single-002. Accessed 29 Sep 2016

HIV+ female, CD4 550

http://wwwnc.cdc.gov/travel/destinations/clinician/immune_compromised.mission_disaster/brazil?s_cid= ncezid-dgmq-travel-single-002. Accessed 29 Sep 2016.

Q1: Which of the following indicated vaccines should not be administered to this patient?  Hepatitis A  Hepatitis B  Rabies  Typhoid oral (Ty21a)**  Yellow fever

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HIV+ female, CD4 550 Malaria Risk

http://wwwnc.cdc.gov/travel/yellowbook/2016/infectious-diseases-related-to-travel/yellow-fever-malaria- information-by-country/brazil#4751. Accessed 29 Sep 2016.

Q2: Which ART regimen has the lowest risk for drug-drug interactions with malaria prophylaxis?

 Abacavir/ lamivudine/ dolutegravir**  Tenofovir/ emtricitabine/ rilpivirine  Tenofovir/ emtricitabine/ efavirenz  Abacavir/ lamivudine/ darunavir/ ritonavir  Tenofovir/ emtricitabine/ darunavir/ cobicistat

HIV+ female, CD4 550

 Vectorborne illness risk in Brazil  Dengue virus  Chikungunya virus  Zika virus  American trypanosomiasis (Chagas

disease)

Travelers’ Diarrhea

 Three or more unformed stools in a 24 hr period

during travel or up to 7 days after

 Oral rehydration plus anti-motility agent such as

loperamide

 Severe non-bloody diarrhea  Azithromycin 1 gram  Ciprofloxacin or levofloxacin 500 mg

Freedman DO et al. N Engl J Med 2016;375:247-60.

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In-Office Interventions

 Administer appropriate vaccinations  Design malaria prophylaxis (if indicated)  Counsel on general traveler advice  Food and water precautions  Oral rehydration  Self-treatment for severe diarrhea  Mosquito protection  Swimming and water exposure hazards

Specific Itinerary-related Topics

 Vectorborne disease personal protection  Altitude sickness  Bloodborne and sexually transmitted

infections

 Respiratory illnesses including

tuberculosis

 Rabies and other zoonotic infections

Specific Itinerary-related Topics

Medical care abroad

 Provide medical condition letter  Research health care facilities  Discuss medical evacuation

insurance

Healthy traveler packing list

CDC Website Counseling Topics

http://wwwnc.cdc.gov/travel/destinations/clinician/immune_compromised.mission_disaster/brazil?s_cid=nc ezid-dgmq-travel-single-002. Accessed 4 Oct 2016

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HIV+ male, CD4 142

 62 yo male plans trip to participate in the Hajj  AIDS diagnosed 14 years ago

 Pneumocystis jiroveci pneumonia

 PMH: hyperlipidemia, hypertension  Medications: TDF/FTC, DRV/r, TMP/S, lisinopril,

atorvastatin

 Viral load undetectable

HIV+ male, CD4 142

 Up to date for MMR, Pneumovax, Prevnar-

13, Tdap, Influenza, Hepatitis A & B

 Tour group with planned meals and hotels,

adventurous eater

 Planned excursions to Cairo, the Nile delta and

Red Sea coast

HIV+ male, CD4 142

Q3: Which one of the following vaccines is indicated and safe for HIV+ patients, AIDS/CD4 < 200 mm3

 Yellow fever vaccine  Zoster vaccine  Meningococcal conjugate vaccine**  Live typhoid (Ty21a) vaccine  Measles-Mumps-Rubella (MMR) vaccine

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Saudi Arabia Vectorborne Illnesses

http://wwwnc.cdc.gov/travel/destinations/clinician/immune_compromised/saudi-arabia?s_cid=ncezid- dgmq-travel-single-002. Accessed 5 Oct 2016.

Dengue Fever in Africa and Middle East

http://wwwnc.cdc.gov/travel/yellowbook/2016/infectious-diseases-related-to-travel/dengue. Accessed 4 Oct 2016

Map of Saudi Arabia

www.mapsofworld.com. Accessed 4 Oct 2016.

Egypt Vectorborne Illnesses

http://wwwnc.cdc.gov/travel/destinations/clinician/immune_compromised/egypt?s_cid=ncezid-dgmq- travel-single-002. Accessed 5 Oct 2016.

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HIV+ male, CD4 142

 Patient inquires about risk for schistosomiasis

while in Egypt

 Acquired by swimming or bathing in fresh water

rivers and lakes

 Cercariae forms penetrate intact skin  Endemic areas include the Nile River valley and

lakes but not the delta region or the Red Sea

HIV+ male, CD4 142

 Vaccination recommendations  Typhoid Vi vaccine  Meningococcal conjugate vaccine  Counseling for avoidance of vector-borne

and zoonotic illnesses

 General pre-travel counseling  General post-travel counseling

Post-Travel Evaluation

 Advise patients to seek evaluation post-travel

 Fever  Chronic diarrhea  New rash

 Most common diseases

 Malaria  Typhoid  Dengue  Rickettsial infections  Diarrhea

Freedman DO et al. N Engl J Med 2006;354:119-30

References

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Freedman DO, Chen LH, Kozarsky PE. Medical Considerations before International Travel. N Engl J Med 2016;375:247-60.

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Freedman DO, Kotton CN. Immunocompromised Travelers. In: Centers for Disease Control and Prevention. CDC health information for international travel 2016. New York: Oxford University Press, 2016:622-33.

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http://wwwnc.cdc.gov/Travel. Accessed 29 Sep 2016.

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Freedman DO, Weld LH, Kozarsky PE, et al. Spectrum of Disease and Relation to Place of Exposure among Ill Returned Travelers. N Engl J Med 2006;354:119-30.