Information for the patient : Travelling with HIV

T RAVEL CAN BE ONE OF THE MOST RE WARD ING AND PLEASUR able ex pe ri ences. It can boost your mo rale and pro vide im por tant new per spec tives. How ever, travel to some for eign coun tries is as so ci ated with an in creased risk of in fec tions be cause of ex po sure to dif fer ent and of ten ex otic patho gens, es pe cially in topi cal cli mates. Al though most trav el lers can eas ily clear these patho gens with ap pro pri ate treat ment, the pres ence of hu man im mu no de fi ciency vi rus (HIV) in fec tion im poses added risks. Be fore fi nal iz ing travel plans, the HIV-i nfected per son needs to ob tain in for ma tion on a va ri ety of sub jects: re stric tions at bor der cross ings; in fec tious risks, in clud ing ma laria, tu ber cu lo sis and trav el lers’ di ar rhea; im mu ni za tions re quired and rec om mended; health care re sources abroad, es pe cially for those at risk for com pli ca tions of HIV in fec tion; pos si ble in ter ac tion be tween medi ca tions for HIV-r elated con di tions and pro phy laxis or treat ment of in fec tious dis eases; sun pho to sen si tiv ity in duced by medi ca tions; and health in sur ance cov er age. Thus, trav el lers with HIV in fec tion must be es pe cially dili gent in dis cuss ing their travel plans and itin er ary with their phy si cians. Re mem ber that you are the only one who can de cide what risks are ac cept able for you. The role of your phy si cian is not to tell you where to go or not to go. His or her role is to ex plain the risks clearly to help you make your plans. This re view ad dresses prob lems of the adult trav el ler only.

T RAVEL CAN BE ONE OF THE MOST RE WARD ING AND PLEASUR - able ex pe ri ences.It can boost your mo rale and pro vide im por tant new per spec tives.How ever, travel to some for eign coun tries is as so ci ated with an in creased risk of in fec tions because of ex po sure to dif fer ent and of ten ex otic patho gens, espe cially in topi cal cli mates.Al though most trav el lers can eas ily clear these patho gens with ap pro pri ate treat ment, the pres ence of hu man im mu no de fi ciency vi rus (HIV) in fec tion imposes added risks.
Be fore fi nal iz ing travel plans, the HIV-i nfected per son needs to ob tain in for ma tion on a va ri ety of sub jects: re strictions at bor der cross ings; in fec tious risks, in clud ing ma laria, tu ber cu lo sis and trav el lers' di ar rhea; im mu ni za tions re quired and rec om mended; health care re sources abroad, es pe cially for those at risk for com pli ca tions of HIV in fec tion; pos si ble inter ac tion be tween medi ca tions for HIV-r elated con di tions and pro phy laxis or treat ment of in fec tious dis eases; sun pho tosen si tiv ity in duced by medi ca tions; and health in sur ance cover age.Thus, trav el lers with HIV in fec tion must be es pe cially dili gent in dis cuss ing their travel plans and itin er ary with their phy si cians.
Re mem ber that you are the only one who can de cide what risks are ac cept able for you.The role of your phy si cian is not to tell you where to go or not to go.His or her role is to ex plain the risks clearly to help you make your plans.
This re view ad dresses prob lems of the adult trav el ler only.

SUS CEP TI BIL ITY TO IN FEC TIONS
The types of in fec tions en coun tered by trav el lers vary with the geo graphi cal lo ca tion, sea son of the year and the ac tivities pur sued.For ex am ple, you are more likely to de velop a gas tro in tes ti nal in fec tion while trav el ling in a de vel op ing coun try and stay ing with lo cal resi dents than while va ca tioning at a five-star re sort ho tel in Scan di na via.The risks of travel to west ern Europe, Aus tra lia, Ja pan and the United States are simi lar to those you might en coun ter in Can ada.
If you are plan ning to travel to tropi cal ar eas you should arrange to have your pretravel as sess ment at least six weeks be fore de par ture, be cause you will likely re quire a number of vac ci na tions (or in ocu la tions).Your phy si cian should carefully re view your itin er ary and as sess your im mune status (CD4 cell count) in or der to iden tify your risks for in fec tious diseases.In fec tions to which a trav el ler might be ex posed are dis cussed in the fol low ing cate go ries: gas tro in tes ti nal in fections, res pi ra tory tract in fec tions, vector-borne dis ease, sexually trans mit ted dis eases (STDs) and oth ers, in clud ing op por tun is tic in fec tions.Vaccine-preventable in fec tions are re viewed at the end of this sec tion.Gas tro in tes ti nal in fec tions: Gas tro in tes ti nal in fec tions caus ing nau sea, vom it ing or di ar rhea oc cur in up to 40% of visi tors to de vel op ing coun tries where fe cal con tami na tion of food and wa ter is usual.Many pa tients with HIV in fec tion are more sus cep ti ble to these in fec tions be cause of low stom ach acid.If you have chronic di ar rhea be fore travel, the su per impo si tion of an other in fec tion may cause se ri ous ill ness re quiring hos pi tali za tion.In stead of be ing a self-limited ill ness, as is usu ally the case in per sons with a nor mal im mune sys tem, trav el lers' di ar rhea may be pro longed or the bac te ria may leave the gut and en ter the blood stream in HIV-i nfected persons.Ex am ples of gas tro in tes ti nal in fec tions that oc cur with a greater fre quency and/or se ver ity in HIV-i nfected in di vidu als include hepa ti tis A, toxin-producing Escheri chia coli, cam py lobac ter, sal mo nella, shigella, cryp to spo ridia, iso spora and cy clo spora.
In de vel op ing coun tries, you should avoid the fol low ing to re duce ex po sure to these or gan isms: food and bev er ages that are at high risk of be ing con tami nated, such as raw or under cooked shell fish, fish, meat or eggs, raw, un peeled fruits and vege ta bles; tap wa ter and ice; and un pas teur ized mild and milk prod ucts.Don't eat food from street ven dors.Eat only well cooked foods but drink lib er ally very hot or com mercially bot tled bev er ages.You should boil wa ter to en sure destruc tion of cryp to spo rid ium, a mi cro scopic para site that is not killed by iodine-containing pu ri fi ers that are ef fec tive against bac te ria and vi ruses.
Daily an ti bi otic pro phy laxis has been shown to be ef fec tive in pre vent ing many of the bac te rial causes of travel-related diar rhea.Be cause of the in creased risk of ac quir ing these in fections, and the po ten tially se vere con se quences of the en su ing ill ness, an ti bi otic pro phy laxis should be con sid ered for HIV-infected trav el lers with CD4 counts less than 250 who plan to travel in high risk ar eas for less than one month.If you are taking a daily dose of co tri moxa zole (Sep tra, Glaxo Well come Inc; Bac trim, Hoffmann-La Roche Ltd), there is no need to add an other an ti bi otic.Keep in mind that bac te rial re sis tance to co tri moxa zole is a fre quent prob lem in many de vel op ing coun tries.If you are not on an ti bi otic pro phy laxis, the most effec tive regi men is a once-daily dose of cipro floxa cin (500 mg), nor floxa cin (400 mg) or ofloxa cin (300 mg).You should start an ti bi otic pro phy laxis one day be fore travel and con tinue it for two days af ter de par ture from a risk area.Since in di vidu als with HIV in fec tion are also at higher risk for ad verse drug re actions, you should weigh the risks and bene fits of an ti bi otic prophy laxis with your phy si cian.Those trav el ling off the usual tour ist routes are at great est risk.If you de cide not to take anti bi otic pro phy laxis, your phy si cian should give you a pre scription (filled be fore de par ture) for a three-to five-day course (one tab let twice daily) of these same an ti bi ot ics to be used for self-treatment of trav el lers' di ar rhea.Lop era mide (Imo dium, Jans sen Phar ma ceu tica Inc) is also very help ful in re liev ing di ar rheal symp toms but should be avoided if you de velop severe di ar rhea as so ci ated with high fe ver or blood in your stools.Lop era mide alone is of ten suf fi cient for the treat ment of mild di ar rhea.How ever, the com bi na tion of lop era mide and an an ti bi otic ap pears to be more ef fec tive than ei ther drug used alone.
If you de velop di ar rhea, drink eight to 10 glasses of liq uid per day.Try to in clude in your diet or ange juice, ba nanas and po ta toes to re place po tas sium losses and broth or soups to re place so dium.Also, add ex tra salt to your food.Avoid spices, fried foods, milk prod ucts, caf feine and choco late.Some authors sug gest that your food in take should mir ror the con sis tency of your stools; liq uid diet for wa tery stools, soft food for semi solid stools and solid food for nor mal stools.Res pi ra tory tract in fec tions: Up per res pi ra tory tract in fections (eg, 'flu) are not un com mon in trav el lers, proba bly because of ex po sure in crowded con di tions (eg, over crowded pub lic ve hi cles, mar kets and econ omy class air craft cab ins).Since chronic si nus in fec tions are fre quent in HIV-i nfected persons, changes in air craft cabin pres sure may ex ac er bate an un der ly ing in fec tion.Lib eral use of na sal sprays or oral de conges tants (pills) are rec om mended be fore land ing if you are suf fer ing from si nus prob lems.In flu enza out breaks oc cur annu ally in the south ern hemi sphere from April to Sep tem ber.There fore, in flu enza and pneu mo coc cal vac cines should be up dated.Hae mo phi lus in flu en zae type b (Hib) vac cine is now rec om mended for all HIV-i nfected in di vidu als re gard less of their travel plans.Al though tu ber cu lo sis (TB) is rare in trav ellers, the risk of in fec tion in creases with pro longed stay abroad.Since TB and HIV are double-trouble, a TB skin test should be ad min is tered be fore travel (as a base line) and af ter a prolonged stay in an area where TB ex po sure is likely.Mea sles in AIDS pa tients may be par ticu larly se vere; it is cru cial that HIV-infected chil dren and adults born af ter 1957 be ap pro pri ately vac ci nated against this vi rus.Vector-borne dis eases: Vector-borne dis eases are in fections that are trans mit ted by the bite of an in sect (Ta ble 1).Except for leish ma nia sis and Cha gas' dis ease, the insect-transmitted dis eases listed in Ta ble 1 are not more severe in HIV-i nfected in di vidu als.Ex po sure to in sects can be mini mized by us ing in sect re pel lents con tain ing DEET on exposed parts of the body, wear ing long sleeves and trou sers and sleep ing un der permethrin-impregnated bed nets.Medica tion to pro tect against ma laria should be taken as a pre venta tive meas ure by all trav el lers to ma lari ous ar eas; this is sue should be dis cussed with your phy si cian or a travel medi cine ex pert.It is im por tant to men tion to the phy si cian pre scrib ing the anti ma lari als all the medi ca tions you are on.Many medi cations are bro ken down in the liver and can com pete with one an other for ac cess to the sys tems re spon si ble for drug in ac tiva tion.This may cause a dan ger ous ac cu mu la tion of a drug in your blood and tis sues.STDs: Of sun, sex, sea and sand, only sex is avail able eve rywhere, every day; thus, STDs are among the most com monly re ported in fec tions in trav el lers, in par ticu lar gon or rhea and Other in fec tions in clud ing op por tun is tic in fec tions: HIV-infected in di vidu als are at in creased risk of op por tun is tic in fections, es pe cially when their CD4 count drops be low 250.In tropi cal ar eas, these in fec tions may oc cur more fre quently and may be dif fer ent from those en coun tered in Can ada.Thus, the usual medi ca tions for pre ven tion of op por tun is tic in fec tions should be taken dur ing travel.My co ses are much more frequent in hot and hu mid ar eas.Al though drops for oral in fec tion and cream or ovules for vagi nal and skin in fec tions can be used, it is usu ally more con ven ient and ef fec tive to use a systemic an ti fun gal such as flu cona zole (Di flu can, Pfizer Can ada Inc), itra cona zole (Spo ra nox, Jans sen Phar ma ceu tica Inc) or ke to cona zole (Ni zo ral, Jans sen Phar ma ceu tica Inc).Daily cotri moxa zole is an ef fec tive pre ven tion for Pneu mo cystis car inii pneu mo nia, toxo plas mo sis and in fec tious di ar rhea.However, the in crease in drugresistant in tes ti nal bac te ria in de velop ing coun tries makes co tri moxa zole a much less ef fec tive agent for the pre ven tion of trav el lers' di ar rhea.While tak ing co tri moxa zole, re mem ber to drink lib er ally to avoid de hy dration and to use a sun screen with a sun pro tec tion fac tor (SPF) of 15 or more to pro tect against pos si ble sun sen si tiv ity.If you plan to travel for more than a month, es pe cially if you plan a stay with lo cals, ask your doc tor about per form ing a tu ber cu lin test be fore de par ture and af ter your re turn.This test is use ful even if your im mune sys tem is sup pressed.If you are be ing treated or re ceiv ing pro phy laxis for tu ber cu lo sis, don't stop your drug(s) dur ing travel.

IM MU NI ZA TIONS
Im mu ni za tions or vac cines are of ten pre pared from killed mi cro or gan isms or are 'live' when they con tain an at tenu ated vi rus or bac te ria not strong enough to harm a healthy in di vidual.In the pres ence of a weak ened im mune sys tem, these viruses or bac te ria could theo reti cally cause a se ri ous in fec tion.Thus, it is gen er ally rec om mended that a live vac cine not be given to such in di vidu als, es pe cially some one whose CD4 count is be low 250.Most of these vac cines can be re placed by 'killed' vac cines or those pro duced by ge netic en gi neer ing with no added risk.When a live vac cine is re quired for which no al ter na tive is avail able, eg, yel low fe ver vac cine, the risk of ac quir ing the in fec tion must be weighed against the risk of the im mu ni za tion, each case be ing evalu ated in di vidu ally.
Im mu ni za tions for the trav el ler are of ten di vided into two groups: those re quired for en try into a coun try, usu ally for pub lic health con sid era tions, and those rec om mended for the pro tec tion of the trav el ler.Re quired im mu ni za tions: Re quired im mu ni za tions are those that are nec es sary in or der to be al lowed to cross an in -ter na tional bor der.There are only three vac cines (for yel low fe ver, chol era and men in go coc cal men in gi tis) in this list.Evidence for yel low fe ver vac ci na tion is re quired from trav el lers plan ning to en ter most tropi cal coun tries of Af rica and South Amer ica or some times from trav el lers com ing from in fected or en demic ar eas.Your ex act travel itin er ary should be re viewed to as cer tain whether there is a need for this live vac cine.When the area to be vis ited is con sid ered to be a low risk for in fec tion and your CD4 count is 250 or less, a waiver should be sup plied by your phy si cian.The ap pro pri ate sec tion of the im mu ni zation cer tifi cate (yel low book) should in di cate that a 'med ical con tra in di ca tion' ex ists and the usual of fi cial 'stamp' should be pro vided.To avoid prob lems with health of fi cials over seas, it may be help ful to know that se vere al lergy to eggs is an accept able medi cal con tra in di ca tion to this vac cine.
Yel low fe ver is found in parts of sub-Saharan Af rica, Panama and South Amer ica, but has never been seen in Asia.Since yel low fe ver oc curs only in fo cal geo graphic ar eas (mostly ru ral) in en demic coun tries, it is safe to en ter these coun tries pro vided that you are not vis it ing an area where trans mis sion oc curs.If you are plan ning to travel to an area in which yel low fe ver is found, ob tain ad vice from your pub lic health de part ment or a travel clinic con cern ing the risk of yellow fe ver at your des ti na tion.If you are plan ning to travel to a high risk yel low fe ver zone, then you may be of fered the vaccine.Al though there is a theo reti cal risk of vaccine-associated ill ness in im mu no com pro mised pa tients, HIV-pos itive in di viduals who have taken the vac cine have suf fered no ad verse effects.
Ac cord ing to the World Health Or gani za tion, chol era vaccine is no longer re quired for en try into any coun try.How ever, this in for ma tion has not yet reached im mi gra tion health of ficials in some coun tries of Af rica who in sist on see ing proof of im mu ni za tion.Trav el lers who do not wish to re ceive a chol era shot at a bor der cross ing should be pre pared to 'n eg ot iate' (bakshish) with lo cal im mi gra tion of fi cers.Since the risk of chol era for trav el lers is ex tremely low (fewer than one case/ 500,000 trav el lers) and the vac cine cur rently avail able in Can ada is not very ef fec tive, you should ob tain a vac ci na tion waiver "for medi cal rea sons" from your health care pro vider or travel clinic.
Men in go coc cal vac cine is safe and ef fec tive.It is only required from pil grims vis it ing Saudi Ara bia dur ing the 'Hajj'.To pro tect against men in go coc cal men in gi tis this vac cine is also rec om mended for those spend ing time in Kenya or Tan za nia or in ru ral ar eas of sub-Saharan Af rica, es pe cially dur ing the dry sea son.Rec om mended im mu ni za tions: Travel is usu ally a good oppor tu nity for you to up date your rou tine (child hood and adult) im mu ni za tions if they have not been given lately.These include diph the ria, teta nus and po lio (every 10 years) in flu enza (an nu ally), mea sles, pneu mo coc cus and Hib (once).Hepa ti tis B vac cine is also safe; you should re ceive it be fore long term travel or if you plan to have new sex ual part ners dur ing your trip.Ask your doc tor about the pos si bil ity of a dou ble dose sched ule if you are im munocom pro mised.Sev eral other vaccines are rec om mended for cer tain geo graphic ar eas and CAN J IN FECT DIS VOL 6 NO 6 NO VEM BER/DE CEM BER 1995 types of ac tivi ties.Hepa ti tis A vac cine is very safe and ef fective.It pro tects against a vi rus trans mit ted through con taminated food and wa ter.It is rec om mended to all HIV trav el lers plan ning to travel to de vel op ing coun tries.If you in tend to travel for pro longed pe ri ods (longer than three months) or to ven ture off main tour ist routes into ru ral ar eas, the new in ac tivated vac cine against ty phoid fe ver (Ty phim vi, Connaught Labo ra to ries) is rec om mended.Japa nese en cepha li tis vaccine is rec om mended if you are trav el ling for sev eral weeks in ru ral ar eas of South east Asia, es pe cially dur ing the mon soon (sum mer) months.Ra bies vac ci na tion is avail able for those trav el lers who in tend to spend three months or more in an area where ra bies is a con stant threat.In for ma tion re gard ing ra bies en demic ar eas can be ob tained from a travel clinic or pub lic health de part ment.Al though tu ber cu lo sis is found through out the de vel op ing world there is no highly ef fec tive vac cine.Since the only vac cine avail able, BCG, is a live vac cine, it is not rec om mended for HIV-i nfected per sons.

TRAV EL LERS WITH SPE CIAL NEEDS
AIDS pa tients and those on HIV medi ca tions such as zi do vudine (AZT) of ten suf fer from ane mia.Dur ing air travel, the cabin is only par tially pres sur ized to an equiva lent of around 2500 m.This can cause res pi ra tory dis tress to some one with a he mo glo bin level of 85 g/L or less.To avoid this prob lem, it is quite straight for ward to make ar range ments for oxy gen to be avail able dur ing a flight.Your phy si cian needs to call the air line at least 48 h in ad vance with all the in for ma tion concern ing your con di tion, the date of de par ture, flight number, con nec tions, etc.A pre scrip tion of 2 L/min is usu ally enough and will be suf fi cient for 6 to 8 h of fly ing time.Don't for get to shut off the oxy gen dur ing meals and when you leave your seat.For maxi mum com fort, ask for na sal can nula.Spe cial meals are avail able from most air lines.Ar range ments need to be made by the trav el ler di rectly or by his or her travel agent.Drink lib er ally dur ing your flight but try to avoid caf feine and alco hol.Car bon ated bev er ages will in crease ab domi nal dis tension and should be avoided if you al ready have such a prob lem.You can eas ily bring herbal teas with you for use dur ing flight.
If you need a wheel chair, don't hesi tate to ask for one when you ar rive at the ter mi nal.An agent from the air line can as sist you with lug gage check-in and dur ing all for mali ties.Travel it self is ex haust ing.Save your en ergy for your va cation!Many ho tels have spe cial rooms to ac com mo date wheelchairs.
If you need to use a blad der cathe ter, re mem ber to fill the 'balloon' with wa ter and not with air be fore air travel.With de pressuri za tion dur ing flight the air will ex pand and po ten tially could dam age the urine pas sage.
If you are le gally blind, you might be re fused on board a ship, even if you are ac com pa nied by a sighted per son.Cruises are ex pen sive; be sure to check for any re stric tions be fore you buy your ticket.

RE STRIC TIONS FOR CROSS ING BOR DERS
Over 50 coun tries have poli cies that dis crimi nate against HIV-i nfected trav el lers, mi grants and stu dents.Many coun tries re strict only cer tain classes of trav el lers.For ex am ple, migrant work ers and for eign stu dents of ten need to be screened for HIV, whereas short term tour ists are usu ally ex empt.In forma tion on the coun tries re quir ing such a test changes rap idly.You should check with con su lates or em bas sies be fore making ar range ments for your trip.Ta ble 2 is a rep re sen ta tive list of some coun tries in which re stric tions ap ply.
The trans por ta tion of drugs, such as mor phine and other opi ates, and of sy ringes and nee dles may com pli cate the travel ler's pas sage through cus toms.Thus, a let ter and pre scription from your phy si cian is es sen tial.Keep in mind that im mi gra tion of fi cials in some coun tries will be search ing luggage for drugs such as zi do vu dine or di dano sine in or der to iden tify HIV-i nfected in di vidu als.Chang ing the la bels on your pill con tain ers will rarely help to avoid this prob lem be cause cus toms of fi cials usu ally rec og nize the drugs eas ily.tions over seas; take a sup ply that will last for the du ra tion of your trip.Also, you might wish to send your medi ca tion by mail or cou rier in ad vance to the first ad dress on your itin er ary; this ap proach usu ally works quite well.

WHEN YOU RE TURN
Back home, you may ex pe ri ence un usual symp toms.Do not hesi tate to con sult your phy si cian for ad vice and pos si ble treat ment.Any fe ver should be evalu ated as a medi cal emergency.Ma laria should al ways be the first di ag no sis to be ruled out af ter a stay in a tropi cal area even if you took che mo prophy laxis as pre scribed.Since fe ver is a com mon find ing in those in fected with HIV, ma laria is not usu ally con sid ered.Men tion to your phy si cian that you have re cently re turned from a ma lari ous area and that you wish to have blood films ex am ined for ma laria.

CON CLU SIONS
Be ing HIV-pos itive or hav ing AIDS should not pre vent you from en joy ing the re wards of travel if you are aware of the risks in volved and have taken the nec es sary pre cau tions to mini mize them.The risk of ac quir ing an in fec tious dis ease is in creased by trav el ling off the usual tour ist routes in de vel oping coun tries and by fail ure to take rea son able pre cau tions con cern ing food, wa ter and in sect bites.The se ver ity of a travel-related ill ness may be re lated to your level of im mune func tion (CD4 count) and gen eral health status be fore de par -ture.The most im por tant ques tion to ask is: "Do the bene fits of travel ex ceed the risks?"Af ter dis cus sion with your health care pro vider, per haps with the as sis tance of a travel medicine ex pert, you should be able to come to an in formed de cision.How ever, it would be an un der state ment to say that many phy si cians are para noid about the haz ards of over seas travel be cause they do not fully ap pre ci ate the ways to prevent ill ness and/or be cause they have never ex pe ri enced the pleas ure of travel them selves.The fi nal de ci sion to travel should not be made by your health care pro vider; it should be yours, and yours alone.

TA BLE 1 Vector-borne dis eases
Cen tral and South Amer ica syphi lis.HIV-i nfected per sons have the po ten tial to de velop an ag gres sive form of syphi lis that may in volve the brain and become re sis tant to con ven tional treat ment.You should al ways use a con dom dur ing sex ual con tact with a new part ner to avoid ex po sure to other STDs and to avoid spread ing HIV.Since chronic car riage of hepa ti tis B is more fre quent in HIV-i nfected in di vidu als, your hepa ti tis B im mune status should be assessed and vac ci na tion should be se ri ously con sid ered if you are not al ready im mune.

TA BLE 2 HIV test re quire ments of se lected coun tries Coun try Re quire ment for HIV test ing
UnitedStates cus toms agents are par ticu larly good at it!Keep in mind that you may have dif fi cul ties ob tain ing your medi ca -For eign ers work ing as en ter tain ers (es pe cially art ists, danc ers and sing ers) and stu dents from Af rica Al ge ria, An ti gua and Bar buda, Aus tria, Be lize, Brit ish Vir gin Is lands, China*, Czech Re pub lic, Egypt, Ger many, Greece, In dia, Libya*, Papua New Guinea, Po land, Qatar*, Saudi Ara bia*, most coun tries of the former So viet Un ion, St Kitts and Ne vis, Syria, Turks and Cai cos Is lands, United Arab Emir ates Stu dents and/or for eign resi dent work ers (for stays rang ing from a few days to 12 months) Aus tra lia, Ku wait, Libya, Phil ip pines*, Po land, Paki stan* For eign ers ap ply ing for per ma nent resi dence vi sas or for prolonged stays An ti gua and Bar ba dos, Aus tra lia, France, Hun gary, Sin ga pore, South Af rica, Sri Lanka, Thai land, Tur key, United States † Visi tors sus pected of hav ing AIDS may be re fused en try or may be re quired to be tested for HIV *Ex clud ing dip lo mats; † May ap ply for a waiver in ad vance if plan ning to at tend a con fer ence, re ceive medi cal treat ment, visit rela tives or do busi ness.HIV Hu man immu no de fi ciency vi rus