Travel-related illnesses – especially diarrhoea, respiratory complaints and malaria – are common among HIV-positive sub-Saharan African migrants visiting their countries of origin, according to a study by Dr Thierry Pistone of CHU Bordeaux, Department for Infectious and Tropical Diseases in France, and colleagues, published in the online edition of Travel Medicine and Infectious Disease. Overall, 38% of individuals experienced at least one health event during or shortly after travel. Risk factors included a low-level viral load and not receiving medical advice before departure about travel-related health risks.
“Because consultation conducted in a specialized pre-travel clinic was not systematically offered, some participants might have missed dedicated pre-travel medical advice,” comment the investigators. “Malaria prophylaxis and travel-related vaccinations are not refunded by the French Social Security and low awareness of health risks during travel is clearly recognized among migrants visiting friends and relatives.”
A quarter of HIV-positive people in France are migrants from sub-Saharan Africa. Excellent responses to antiretroviral therapy mean that many make frequent and prolonged visits to their countries of origin.
Investigators in France therefore designed a study which aimed to describe the incidence and type of health problems experienced during and shortly after travel and to determine their risk factors.
The 264 participants, all of sub-Saharan origin, were recruited at 24 clinics across France between 2006 and 2009. All were taking stable antiretroviral therapy and had a viral load below 200 copies/ml (94% had an undetectable viral load below 50 copies/ml). Individuals taking a trip to a sub-Saharan country lasting between two weeks and six months were eligible for inclusion.
Data were collected on the proportion of people who received pre-travel health advice, especially about the prevention of diarrhoea and malaria, and the use of anti-malarial prophylaxis. Information was gathered on the incidence of health problems and their type during travel and within one month of return to France.
The majority (59%) of participants were female and the median age was 41 years. Pre-travel CD4 cell counts ranged between 66 to 1600 cells/mm (median 439 cells/mm3).
The main reason for travel (89%) was to visit family and friends. All participants travelled to their country of origin, with 49% visiting central Africa and 46% west Africa. The median duration of travel was five weeks.
Pre-travel advice on diarrhoea and vector-borne disease (such as malaria) was provided to 92% of people. Just over half (56%) of participants reported using at least one method to prevent vector-borne diseases, such as mosquito repellents or bed nets. Malaria prophylaxis was provided to 98% of people and two-thirds of individuals reported being adherent to this medication.
Travel vaccination data were available for 206 people, with 91% vaccinated against yellow fever, 71% for diphtheria-tetanus-polio and 31% for typhoid fever.
At least one health event was reported in 100 (38%) migrants, among whom 13 had two events. Among the overall 113 events, 76 (67%) occurred during travel and 56 (50%) required medical care. Thirty-eight (68%) of these sought medical care during the travel. Forty-five were outpatient visits, 10 hospitalisations, and 1 was a medical evacuation.
The most common health problems were diarrhoea and gastrointestinal complaints (26%), respiratory illness (18%) and malaria (15%).
One patient died because of malaria. This patient was a 26-year-old Nigerian woman whose pre-travel CD4 cell count was 354 cells/mm3. She showed lack of adherence to her malaria prophylaxis and despite admission to intensive care died because of acute respiratory distress syndrome.
“The single case of fatal malaria shows the potential severity of this disease, especially among HIV-infected immunocompromised individuals, and the need for careful anticipation of travel and tailored counselling to include relevant advice on malaria prophylaxis,” comment the authors.
The main risk-factors for travel-related health events were a viral load between 50 copies/ml and 200 copies/ml (aOR = 4.31; 95% CI, 1.41-13.1) and lack of pre-travel medical advice (aOR = 3.62; 95% CI, 1.38-9.47).
A malarial fever or unspecified fever was strongly associated with lack of pre-travel advice regarding diarrhoea and vector-borne infections (aOR = 4.60; 95% CI, 1.24-17.1).
“Our results highlight the need to tailor counselling towards adherence to pre-travel medical advice regarding diarrhoea and vector-borne diseases prophylactic measures,” conclude the authors. “If an earlier pre-travel counselling is tailored, HIV-infected migrants could maintain a sustainable undetectable HIV plasma viral load, and thus minimize the risk of travel-related health events… A specific education program directed towards HIV-infected sub-Saharan migrants visiting their native country could help to achieve these goals.”
Pistone T et al. Travel-related health events and their risk factors in HIV-infected sub-Saharan migrants living in France and visiting their native country: the ANRS VIHVO cohort study. Travel Medicine and Infectious Disease, online edition, https://doi.org/10.1016/j.tmaid.2019.03.010.