International Travel with HIV

two years. This is his first article in AIDS TREATMENT NEWS.
Because of the upcoming VIII International Conference on AIDS
(July 19-24 in Amsterdam), we asked him to research what people
with AIDS or HIV should know -- about food safety, medical care,
vaccinations, and crossing borders -- on international travel in
general. Unfortunately, there is no comprehensive source of such
information; what we did find is in the article below. JSJ

Going to a foreign country, especially the large majority of
nations where English is not dominant, can invert one's world.
Nothing is easy, and even mundane chores like shopping for food
or getting the laundry done suddenly require learning a whole new
set of steps.

The strain of daily life in a new country can be stressful.
Many people get ill while traveling, especially since they are
meeting new gastrointestinal and other microbes for which their
immune systems are unprepared. What is true of many people is
even more true of people with HIV, but this does not mean they
cannot travel. "People with HIV who are reasonably smart about
it can do anything everyone else can. They just have to be more
compulsive about the normal precautions," said noted AIDS
specialist Marcus Conant, M. D. .

Medical Precautions

To get a sense of the reasonable precautions to take while
traveling in unfamiliar lands, AIDS TREATMENT NEWS talked with
Susan Jacobson, M. D., an infectious disease physician by
training, who runs a travel medicine clinic and also sees
patients at the East Bay AIDS Center in Berkeley, California.

Dr. Jacobson noted the dearth of information any physician
has about the issues of traveling with HIV. Nobody is
correlating individuals' experience. There are nevertheless many
obvious considerations.

Unlike some other physicians, Dr. Jacobson feels that no
area of the world is a no-no for people with HIV. "There are
just places to be a little more careful and a little less
adventuresome."

Certain parts of Africa and Asia, where medical care is
poor, might be avoided depending on how isolated you will be --
and how much money you have. The key is to go with more drugs
and be extra careful about sanitation.

Travelers' diarrhea is perhaps the biggest threat around the
world for everybody, striking as many as half of all visitors in
certain countries. Of course, it threatens those with HIV worst
of all. Fortunately, Septra/Bactrim (cotrimoxazole), which many
already are taking to prevent pneumocystis, is a cheap and
excellent preventive for gastrointestinal infections. Two
tablets of Pepto-Bismol four times a day also helps, but the
"gold standard" is the costly antibiotic ciprofloxacin (500 mg
per day).The same agents are also good for treating diarrhea once
it occurs.

Usually, however, prophylaxis for diarrhea is not
recommended unless you are very immunosuppressed. A wide range
of microbes, including E. coli, shigella and salmonella bacteria
plus amoebas and such exotics diseases as cholera and typhoid
fever, can cause diarrhea. The safest way to avoid them is to
look after your food and water:

"Boil it, cook it, peel it or forget it is the rule to
follow," says Dr. Jacobson. (This is also important in Europe,
where undercooked meat is a major source of toxoplasmosis in
people with AIDS.)

Two diseases that cause not only diarrhea but much worse
effects are typhoid fever and cholera. Vaccines exist for them,
but the cholera one is not very effective and the killed typhoid
vaccine has many side effects. Assiduous attention to
sanitation, including proper cooking and safe drinking water,
should help to prevent these diseases in places where they are
common.

There is a live typhoid vaccine that is usually safer than
the killed one, but vaccines containing live, attenuated strains
of bacteria and viruses are dangerous for people with HIV. Their
immune systems may not be strong enough to resist even these
weakened microbes.

Generally recommended killed vaccines include
tetanus/diphtheria and polio boosters; measles and hepatitis B
(if susceptible); and pneumococcus and hemophilus influenza type
B for all HIV-positive persons. Gamma globulin shots to ward off
hepatitis A for up to four months is also a good idea when
traveling to poor countries where the disease is widespread.

Vaccines have been controversial because it is feared that
stimulating people's immune system might increase the rate of HIV
reproduction. This has not turned out to be a major concern
given the small amounts of material used in vaccines. Dr.
Jacobson noted that studies of immune system function after
vaccination have not found any decline. Of greater concern is
that the effectiveness of vaccines goes down along with the T-
helper count. Vaccines are not very useful in people diagnosed
with AIDS.

Getting Emergency Care

HIV and AIDS are not that great a problem when traveling
because the illnesses related to them often (but by no means
always) develop slowly so that there is plenty of time to go home
or at least find appropriate care. The most frequent emergency
facing travelers with HIV involves automobile accidents, just as
with everyone else.

If you need to see a doctor outside the U. S., try to find
out where the U. S. consulate staff or the local expatriate
community goes. That is a useful source of safe, expert medical
assistance.

U. S. consulates and other agencies do provide lists of
physicians, but their reliability is questionable. When AIDS
TREATMENT NEWS enquired at the State Department about its lists,
we were told that the Department cannot recommend specific
doctors. The lists that consulates maintain merely record all
those doctors who expressed an interest in treating Americans.

American consular officials also can help you contact
friends or family back home for money to pay the doctor. They
can even loan you money in case of dire need. (But note that
they then stamp your passport that you owe the government money.
This makes the document unusable except for the return trip until
you repay the loan.)

The financial entanglements of emergency foreign care are
fearsome. According to John Schmidt, a partner in a gay-
oriented insurance agency, "There's not a person I know who will
cover [HIV-related] conditions" when traveling.

AIDS and HIV fall under the "pre-existing conditions"
exclusion clause of all types of traveler's insurance (including
that for canceled tickets). If you already have health insurance
that covers you in your trip's destination, you are lucky.

Know the Country

To get around the State Department's lackadaisical services,
John Slama of Winship Travel, which counts many HIV-positive
people among its clients, recommends:

"Educate yourself about the countries you're going to. Find
out about the AIDS situation there and about repression of local
gays. It's good to develop contacts among the residents so that
you can obtain reliable doctors and lawyers."

One good place to start accumulating this information is in
the Spartacus Guide for Gay Men (Bruno Gmnder Publications, U. S.
office: 100 E. Biddle St., Baltimore, MD 21202; telephone:
410/727-5677), which is sold in gay bookstores and lists legal
conditions along with health and service organizations by
country.

Slama, like Dr. Jacobson, notes that there is a need for
someone to collect and disseminate individuals' actual
experience. Theory counts for little in travel, where one's good
times can be wrecked by the whim of some immigration or other
official. Even coming back to the United States can be
problematic for people packing a load of strange medicines, and
HIV-positive resident aliens take a special risk.

Still, international borders here and elsewhere have not
proved a consistent hassle. So, have fun this summer. Just keep
in mind the limits of your body, try to bone up on local
conditions before you leave home, and you should be all right.

Note: For additional food-safety information, whether for
traveling or otherwise, obtain the brochure "Eating Defensively:
Food Safety Advice for Persons with AIDS," by the U. S. Food and
Drug Administration. It includes a short section on
international travel. You can obtain a free copy from the CDC
National AIDS Clearinghouse, 800/458-5231, Monday through Friday
9 a.m. through 7 p. m. Eastern time.