The Positive Side

Spring/Summer 2006 

Vacationing with the Virus

Been denying your wanderlust? With some careful planning, the exhilaration of travel could be yours once more

By Walter Armstrong

WANT TO GET AWAY FROM IT ALL THIS SUMMER? Go for it. Give the HIV-positive finger to global terrorism, avian flu and every other fear, and hop a plane to your dream destination. If you’re lucky, you’ll lose your tired old self in a strange new land — and come home, renewed, a citizen of the world.

Plus, it’s what people with HIV do. Soon after testing positive in 1989, Arvin Thomas took a six-month leave of absence and went backpacking through Asia. “I was trying to sort out my head. It was the most amazing thing I ever did for myself. There was no fear — I found a complete sense of freedom,” he says of his you-only-live-once adventure. “There is such a liberating feeling to being in a foreign country. You can be anyone you want to be and do anything you want to do.” But even more than that, he says, “It was a very humbling experience to meet so many people who had so much less than I had and yet invited me to share their home, their food. I realized how blessed I really am — and [decided] to stop whining about being positive.”

Still, as always for the HIV enhanced, the stakes are raised. A routine setback, such as a bout of travellers’ diarrhea in a lonely room far from home where you can’t negotiate a local call or the local currency, can set off emergency sirens in your mind. But the flip side is, you can stroll down the Champs d’Elysées at twilight dressed all in leather, lace or feathers and forget all about HIV.

What you can’t forget is to take your meds. And that’s where we at The Positive Side come in. Because we want your trip to be as safe and comfy as possible and, yes, because we love to nag. So prepare yourself for a crash course in Viral Vacationing 101.

Vacation Vax

Part of the fun in travelling is dreaming up the trip. If you’re looking for an HIV-savvy travel agent, it pays to go gay, since they will have had the most experience with positive peregrinators; check out the International Gay and Lesbian Travel Association at www.iglta.org. For do-it-yourself planners, access to the Internet is indispensable. While Googling the cheapest flights to your destination and sights not to miss, take note of health need-to-knows, starting with local diseases you will want to miss. (Keep in mind that the health problems travellers most commonly face are injuries from motor vehicle accidents, diarrhea and sexually transmitted diseases — not more exotic fare like Japanese encephalitis, malaria or avian flu.)

Still, you’ll need to consider needle work. If you’re heading to the U.S., Europe or Down Under, you’re unlikely to have to roll up your sleeve for any particular vaccination. Canadians are usually immunized in childhood against such nasties as diphtheria, whooping cough, tetanus, polio, measles, mumps and rubella — but check with your doctor to see if you need a booster. Hepatitis A and B are vital vaccines for the wary traveller.

Vacations in the developing world, however, may call for some shots, depending on where and when; certain countries require specific vaccinations for entry. Check out the Public Health Agency of Canada’s Travel Health Program (THP) at www.TravelHealth.gc.ca for more info. Every year sees awful outbreaks of diseases that never make headlines, and THP provides updates. And, yes, there’s a special avian-flu page, with recommendations for nervous nellies (sorry, no vaccine exists yet).

Two vax facts: 1. The immunization may take weeks to months to kick in, so plan your visit to Doc accordingly. 2. People with HIV should avoid all “live” vaccines, including yellow fever and vaccinia, since a tiny case of said disease may be more than your immune system can handle.

La Travel Clinique

If you’re short on time (but not on cash), drop by your local travel clinic. (For a national list, click on www.phac-aspc.gc.ca/tmp-pmv/travel/clinic_e.html.) Many swear by these one-stop shops for health travel needs, where you’ll find not only a specialist in tropical medicine and hygiene (who should be HIV savvy) but a blizzard of brochures and other information. Although your provincial health plan may not cover the visit, the initial consult shouldn’t run you more than $50, with specific vaccinations ranging anywhere from $5 to $250 (but you’d be paying for any travel-related vaccinations at any doctor’s office, anyway).

Travel clinic or no, don’t scrimp at the planning stage. A recent study by Dr. Irving Salit and his colleagues at Toronto General Hospital of Canadian PHAs who travelled internationally revealed some disturbing findings. Of the 290 folks interviewed, 18 percent got so sick during their trip that they needed medical care — a stat higher than their HIV-negative peers’. The top troubles? Pneumonia and other lung-related issues; malaria and other parasitic problems. Notably, fewer than half of the PHAs visiting such mosquito-rich regions as Latin America, Africa and Southeast Asia packed the recommended antimalarial meds. (Ask your doctor about possible interactions between anti-parasite pills and your HIV combo.)

Not surprisingly, only 13 percent of the 290 had visited a travel clinic before their trip, and when asked why not, most said they viewed such medical advice as unnecessary. But you can bet that in retrospect, those PHAs who came home with memories of the holiday from hell thought the cost of a travel-clinic visit would have been money well spent.

To make your packing that much more mindless, we’ve provided a checklist of must-haves — so there’s no excuse for forgetting your meds. For Shari Margolese, PHA writer, speaker and activist, it’s the med she can’t take that causes her biggest travel headache. Margolese, a frequent flier to AIDS conferences worldwide, has to leave home without her beloved medical marijuana: “I travel all the time, but I can’t take my weed across borders. I don’t even like travelling in Canada with it. It’s a problem because it’s the only thing that controls my nausea and vomiting. Alternatives like Dramamine make me so tired that I end up sleeping most of the time.”

Don’t Miss the Dose

Marijuana aside, adhering to HIV medication is tricky for many travellers. In Salit’s study, while half of the PHAs on combo therapy reported doing just fine with their dosing schedule, 30 percent either had difficulty taking their pills or quit taking them entirely. Only a handful had checked with Doc about interrupting their treatment before doing so. The point is not to get permission, but to confirm (1) that a break is safe and (2) whether to stop all meds at once or to phase out — certain drugs stay in your body much longer than others, and so to minimize the risk of resistance, it’s best to keep the level of the entire combo as consistent as possible.

Last year, Margolese got married in Jamaica. After the wedding, she mistakenly packed her HIV meds in her son’s luggage, and when he left, she was forced to go med-free for the rest of her island honeymoon. Suffice it to say, it was not all cool runnin’. “As the week progressed, I began to feel increasingly tired and viralish,” she says. “When I got home, I went to my doctor, got tested and found out I had developed resistance to Kaletra. In a single week! And despite the fact that I went off all my meds at the same time!”

Treatment interruption is risky business. That’s why it’s so disturbing that many of Salit’s pill-stoppers went off their regimen either because they were afraid to cross borders with their meds or because they ran out of doses during their trip — poor excuses for rational treatment decision-making. If you want a vacation with Club Med-Free, plan it with your HIV specialist.

If you’re crossing time zones, you need to address any potential dosing disruption before you get to your penthouse suite at the five-star. “Travel is very complicated for med adherence,” says Louise Binder, chair of the Canadian Treatment Action Council. “I stay on my drug regimen, with the same times from home, and if that means I have to set an alarm in the middle of the night, I do that. I don’t add an hour for every time zone or anything like that.” Binder’s former three-times-a-day combo could have wreaked havoc with her schedule, but it taught her to keep plenty of food bars and bottles of water handy. Now that she’s on a twice-a-day dose, med matters are easier, but with a new twist. “It’s a protease-boosting regimen, so I have to refrigerate the ritonavir,” she says. “That has been the peskiest thing. When I don’t have a fridge in my room, I have to improvise with an ice bucket. And for the plane, I buy those ice packs and a little cooler and I carry the ritonavir with me.”

Others may take a different approach. “I do not want to wake up in the middle of the night to take my meds,” says one PHA emphatically. “If I’m going away for more than a few days, I like to take my meds on the local schedule.” He adjusts to the new time during his first two travel doses, adding or subtracting half the time change to the first, half to the second. But whatever changes you’re tempted to make, don’t make any adjustment that veers off your usual meds routine without first getting the go-ahead from your doctor. Why risk bringing a mutation home as a souvenir?

Water and Food 411

Eating adventurously is a favorite feature of foreign travel. “My biggest joy when I vacation is the food,” Arvin Thomas says. “That’s why I love travelling in Southeast Asia — because you can get almost any kind of food you want — Chinese, Thai, Indian, western food, Starbucks — 24/7 and for a third the price.” Not surprisingly, traveller’s diarrhea is the most common health affliction of the intrepid traveller anywhere hygiene and sanitation leave something to be desired. Most cases are caused by bacteria in water or in raw or undercooked food, although even well-prepared food may contain evil toxins left by the bacteria killed by cooking.

You can’t just guzzle from the tap and gobble street-vendor snacks like a native without expecting some gastrointestinal aftermath. A little vigilance is on order. You know the safe-food-and-water drill: drink only bottled water with sealed caps in restaurants and on the road; be sure to stock the stuff in your room for downing meds and any middle-of-the-night refreshment. Wash and peel all fruit, and avoid cut fruit from local steet vendors. Nix the water fountains and ice in restaurants. Speaking of which, the busier the restaurant, the better — but don’t order from the raw-food section of the menu.

The good news about traveller’s diarrhea is that bouts lasting a day or three won’t ruin your entire vacation. But intense or prolonged diarrhea may indicate a serious problem that needs urgent medical attention. Some PHAs have found that mild diarrhea can be managed with meds of the Pepto-Bismol persuasion. But beware: Some anti-diarrhea drugs, particularly Imodium and Lomotil, increase the amount of time the offending germs stay in the gut. Broad-spectrum antibiotics can beat back many bugs that cause diarrhea (don’t you just love that word!). If you think your trip poses a high diarrhea danger, ask your doctor about packing antibiotics — just in case. “Because believe me,” Binder says, “you can get any bug anywhere, and you can’t always find a doctor.”

Margolese swears that it’s flying itself that poses the biggest risk. “I almost always end up with a cold after airplane travel,” she says. “Now with SARS and avian flu, I am much more conscious of picking up viruses on planes. I don’t go to the extent of wearing a mask, but I’m very conscious of what I touch. And if the person next to me is coughing or sneezing, I look for an open seat elsewhere.”

By the way, if you need medical care while travelling, at best your provincial health plan will cover only limited emergency services and hospitalization. Plus, many foreign health facilities demand cash upfront — regardless of whether or not you have provincial coverage. If you want greater protection, buy single-trip health insurance, which will run you anywhere from, say, $30 for emergency-only coverage to $130 for all-inclusive coverage for a two-week vacation. However, many policies may exclude HIV and any other “pre-existing conditions,” covering only for ailments and accidents that afflict you on your great adventure. (For more info, check out the Canadian Life and Health Insurance Association at www.clhia.ca.)

Margolese is a true travel-insurance adherent, and like many tourists, she learned the hard way that an ounce of prevention (and the premium) is worth a pound…. Years ago, on a trip to Mexico, an ectopic pregnancy sent her into emergency surgery, and without insurance she had to fork over $5,000 in advance. Since then, she has put her travel insurance to good use. For example, on a second trip to Mexico, she was hit with a barrage of Crixivan-related kidney stones, and a local md gave her two scripts — one for a pharmaceutical painkiller, the other for a special tea that she got from a herbalita, and that she still uses.

A Rough Crossing

As Salit’s study reveals, traversing borders with HIV meds is a fraught issue for people with HIV, and no border illustrates this more acutely than the one between Canada and its southern neighbour. The U.S. bans the travel and immigration of all PHAs into the country. The Yanks welcome all guests with an arrival form that includes a question asking if you have a communicable disease (not HIV specifically); for short-term visitors, answering yes is unlikely to lead to denied entry, but there are no guarantees.

Many PHAs simply refuse to put a check in the little box on the form, although that can cause sweaty palms and anxious thoughts in the (inevitably long) line at customs. Binder has entered the U.S. many times without outing herself on the arrival form and never had any trouble. “I am a straight white woman and don’t fit the stereotypical PHA image. If I were a gay man or a person of colour, things might be very different,” she says. “Still, I do not advertise my HIV status. When asked the purpose of my trip, I will not say ‘AIDS conference,’ but ‘health conference.’” A fellow leading Canadian AIDS activist, who requests anonymity because of these draconian travel restrictions, takes a similar tack on his frequent travels to the U.S. “I dress for success, like the average gay white male, no bling or hair products to make me conspicuous,” he says. “I keep my answers very short. But the whole time, my heart is in my throat. I actually practice meditation while waiting in line.”

Still, there’s always the chance that you will be searched, and for Margolese, one of the most annoying issues is where to put her meds. “The risk is if I put them in my luggage, they may not arrive,” she says. “But if I put it in my carry-on, I may be caught.” Margolese errs on the side of health safety by always carrying them with her on the plane. On long trips, she asks her pharmacist to put the meds in generic bottles with a drug label omitting those two adorable acronyms HIV and AIDS.

Now that we’ve filled your head with all manner of fright and frustration, you may feel that, like Dorothy, for a PHA there’s no place like home. But, hey, the international tourism industry is predicting a banner summer in foreign travel, marking a sustained rebound from the dog days triggered by 9/11 and the SARS outbreak. Doing its bit, Toronto will play host to the XVI International AIDS Conference — AIDS 2006 — and what is likely to be the largest-ever get-together of the HIV community in the Americas. You don’t want to miss out on all that, do you?

Or on this: “I have always had the travel bug,” says our anonymous activist. “But when I became quite sick in the early ’90s — no CD4 cells — I was afraid of food-borne illness. Suddenly seeing my horizons shrink was one of the worst parts of having HIV back then.” These days he’s planning a three-week trip to India that he once thought was forever closed to him and his depleted immune system. But now with an undetectable viral load, a CD4 count of 350 and a careful approach to what he puts in his body, he and his partner can voyage out. “We’ll alternate between moving and resting, a few days in a city and then a few driving. I can’t describe how it feels planning for all the places I had always wanted to visit but had given up hope of ever seeing,” he says, a little teary-eyed. “And now I can go.”

Now hurry up or you’ll miss the plane. And don’t forget your passport. Or your meds. Or…. Oh, and have the time of your life!

Walter Armstrong is a freelance writer and editor in New York City who covers HIV and medical issues.

For more info, see the presentation “Making Sure Your HIV Patients are Ready for Travel” by Dr. Gordon Arbess, available at http://www.ohtnmedia.org/rounds/smh/2006_01_17/.

Illustration: © Ian Phillips / www.i2iart.com

Traveller’s checklist

Universal plastic and ATMs may have made traveller’s cheques obsolete, but don’t leave home without the following:

To carry on:

1  passport (valid for more than six months, with visas if necessary)

2  HIV meds

3  vaccinations against infectious diseases, including certificates thereof for entry (if required)

To pack:

4  aspirin, ibuprofen or a Tylenol-type painkiller

5  anti-diarrheals like good old Pepto-Bismol

6  antibiotics for traveller’s diarrhea; rehydration salts for enduring it

7  antifungal creams

8  Benadryl-type antihistamines

9  sunscreen

10  iodine

11  Band-Aids

12  insect repellent and a mosquito net (if recommended)

13  a thermometer

14  a Swiss Army knife (for all those Indiana Jones–style improvisations)

15  condoms and lube

16  a camera… to bring it all back home with you!

Canada welcomes PHAs

Some 20,000 scientists, advocates, doctors, officials and, of course, people with HIV/AIDS (PHAs) are descending on the Metro Toronto Convention Centre from August 13 to 18 for the XVI International AIDS Conference. Dubbed AIDS 2006, this biennial global summit is the single-most important event on the HIV community’s social calendar, fixing the mainstream media’s attention on a preventable pandemic that has infected more than 40 million people worldwide — and killed 25 million others. This year’s theme is “Time to Deliver” — as in deliver on our promises of prevention and, in particular, treatment to the HIV-ravaged developing world.

AIDS 2006 is notably the third International AIDS Conference to be held in Canada — a frequency due in part to the conference’s boycott of the U.S. and its discriminatory visa and immigration policies, namely the restriction on PHAs. And if the past suggests a pattern, Toronto ’06 will make history, as did Montreal ’89 when activists and PHAs seized the stage, and Vancouver ’96 when the protease revolution was launched. In fact, one permanent change has already taken place: thanks to a collaborative effort by the conference organizers and the Canadian government, the Canadian visa application was revised last May and no longer demands that visitors disclose their HIV status.

“We asked the immigration department for a review of the visa application requiring that all people with any communicable and chronic health condition reveal their medical diagnosis on the form. They agreed that the question was much broader than it needed to be to meet Canadian law,” says Joan Anderson, a senior advisor to the Toronto Local Host Committee. The result? The department made a permanent change to the visa application — not just for PHAs or for the conference. The temporary resident visa application now asks specifically only about tuberculosis and any expectation that treatment will be required for a physical or mental health condition that might place demands on Canada’s healthcare system.

The principle that the conference organizers were backing, Anderson says, was that of freedom of travel for PHAs. But she is quick to point out that the revision doesn’t affect immigrants applying for permanent residence, who still must be tested for HIV. “And for visitors, the immigration department still has concern that some people from developing countries coming to the conference may try to stay here once they arrive,” Anderson says. “We are still concerned about problems entering the country, but not specifically for being HIV positive.”

Meanwhile, the U.S. has granted the conference a “blanket waiver,” to allow PHAs to travel to AIDS 2006 via the U.S., despite that country’s travel ban against PHAs. Still, that army of empowered PHAs angry at the world’s sole superpower not only for its ban on HIV travellers but for exporting anti-condom prevention, anti-generic treatment and any number of other policies may seize the conference’s media spotlight with some loud and colourful demonstrations. Stay tuned.

For more info on AIDS 2006, check out www.aids2006.org