YOU ARE HERE:
US Travel Health Warning!
   Last updated: 27.10.04
Why the US HIV Travel ban is seriously damaging our health, by Edwin J Bernard
This month, ahead of the 15th International AIDS Conference in Bangkok, the US city of San Francisco hosts the 11th Conference on Retroviruses and Opportunistic Infections (CROI), generally considered to be the major scientific AIDS meeting of the year.
Fourteen years ago, San Francisco was the location for the 6th International AIDS Conference, which saw international boycotts and mass demonstrations due to the then three-year-old US policy of barring visitors with HIV. This was the last time a US city played host to any international AIDS conference: the 1992 International AIDS Conference was moved from Harvard University to Amsterdam.

End the ban
Currently, the US is one of only 15 countries to effectively ban HIV-positive visitors - along with the likes of Iraq, Libya, Russia and Saudi Arabia -according to the latest information from the Swiss HIV information site, aidsnet.ch.1 Although the US HIV tourist ban has been almost universally criticised - both within and outside the US - the restriction remains after 17 years, and due to the convoluted nature of the history of this discriminatory piece of legislation, requires an act of Congress to remove it.
It is possible to enter the US legally with HIV under certain circumstances - to attend conferences, receive medical treatment, visit close family members, or conduct business - but this requires applying for a stigmatising HIV visa waiver. Even if the waiver is granted - which may take three months or longer to obtain, and requires a personal interview at the US Embassy - the person's passport is endorsed to show that this person may not enter the US without the waiver, which must be renegotiated on each entry. This can cause further HIV disclosure issues on entering other countries, where immigration officers may want to know why the passport holder is barred from the US.
Two years ago, the UK AIDS charity, THT, began a campaign to raise awareness of the ban on US entry restriction for HIV-positive visitors.2 Martin Kirk, THT's Parliamentary and Campaigns officer, acknowledges the limitations of the campaign in terms of changing US policy, but "having said that, we have raised the issue with the US Ambassador, the US Secretary of State for Health, and Bill Clinton. However, apart from Clinton - who said the policy ought to be reviewed - most US officials have been very defensive, citing the other countries that ban visitors with HIV, and will not engage in a proper dialogue."

First ever study on the ban's health effects
Until recently, there had been no research on the physical, emotional and psychological effects of the ban on HIV-positive people. Late last year, however, a study from Brighton and Sussex University Hospitals was presented as a poster at the 2003 European AIDS Conference in Warsaw3.
The study sought to determine whether those attending the Lawson Unit HIV Outpatients' Clinic in Brighton travelled with a visa waiver and/or medical insurance, and to establish how they managed their HAART medications when travelling.
A self-completion questionnaire was given to everyone who attended the clinic in February and March last year. Of 642 attendees, 346 completed the questionnaire, of which 96.5% were male (compared with 90% of all clinic attendees) with an average age of 41 (compared with the clinic average of 40). In total,135 (39%) respondents had travelled to the US since their HIV diagnosis, all but two of them "illegally."

One-in-eight interrupted treatment
The most striking - and worrying - finding of the Brighton study was the way people travelling to the US without an HIV waiver managed their drugs.
Of the 83 respondents on HAART who travelled to the US, 10 (12.5%) stopped their drugs for the duration of their stay. Five chose to take treatment interruptions prior to leaving for the States, and five had problems with mailing their drugs. "We found that people either stopped HAART themselves because of the trip to the States or they attempted to mail their drugs, which was often problematic, says Dr Duncan Churchill, co-author of the Brighton study.

Of the ten who interrupted their treatment, five were on NNRTI-based HAART, which, due to its longer half-life, must be stopped ahead of the other HAART components in order to reduce the likelihood of NNRTI mutations that could lead to clinical resistance. Current BHIVA guidelines4 suggest that the NNRTI should be replaced with a drug with a shorter half-life two weeks prior to stopping all drugs.

In the Brighton study, only of the five on NNRTI-based regimens stopped their NNRTI in the best possible way after consulting with their HIV clinician. This person switched from efavirenz to tenofovir two weeks prior to stopping all drugs. The remaining four stopped their NNRTI two days, one day or at the same time as the rest of their HAART combination.

Of the three people who had short- or long-term problems due to their treatment interruption, one subsequently developed NNRTI drug resistance (Y188L). "This was a highly drug experienced patient who has subsequently run out of options now that he has also developed resistance to T-20," notes Dr. Churchill.

The other two developed intermittent fevers, arthralgia, headaches and diarrhoea, symptomatic of a viral load rebound, whilst in the US.

"Afflicted with a communicable disease"
THT's Kirk is not surprised by these results. "I think it just confirms our fears that people with HIV are still travelling to the US and it seems they will either choose to go on an unplanned drug holiday or they will have their drugs found on them. It's what we've always said will happen."
All the people who stopped their treatment travelled on the green I94-W form which allows citizens of EU countries to enter the US for up to 90 days without any visa, as long as they are not terrorists, communists, convicts or "afflicted with a communicable disease."
According to the website AIDSandtheLaw.com "if the applicant is not aware that HIV is such a disease under US immigration law, he or she could respond 'no.' In that case, the application would not be fraudulent. But if the applicant answers 'no,' while knowing that individuals with HIV are barred from entry, then the applicant has committed immigration fraud, which, if discovered, is an permanent, non-waivable, basis for inadmissibility."5

"The fear of being stopped by immigration officials is entirely understandable and is possibly more damaging than the reality," notes Dr. Churchill. "If you don't realise what is at stake, health-wise, then you may think that stopping your drugs for a fortnight has less consequences than the potential of what could go wrong: 'my holiday will be ruined, I'll have to come straight back, my name will be forever be on a computer, I'll never be able to go back there, I'll have broken the law, they may even take it further, I may have to pay for all of this'...all those fears."

US fear culture
It seems that the US HIV visitor ban's biggest impact is to create a culture of fear around travelling to the US.
The reasons given for temporarily stopping HAART in the Brighton study include a variety of fears. All ten had a fear of being searched at the airport and were afraid of their status being known to immigration. Three also feared that their drugs would be confiscated.
According to counsellor Robert Goodman, counselling supervisor for Brighton Body Positive, the psychological burden of "this insidious ban creates a great deal of apprehension for most HIV travellers to the US. The 'culture of fear' you mention I think sits alongside other feelings of anger, outrage, bitterness, and frustration. This may 'feed' other fears around living with HIV, such as being seen as 'unclean', being denied the choice not to disclose one's status, the implications of that disclosure, and all other forms of discrimination that the HIV population experiences.
"The fact that this is the position of one of the world's most powerful nations feels deeply threatening - and fear-promoting - in itself."
AIDSandtheLaw.com reports that the "Bureau of Citizenship and Immigration Services (BCIS) has issued an 'advisory' policy regarding border inspections regarding HIV/AIDS. BCIS officials should not inquire about HIV status unless there are physical symptoms of illness or the individual makes an unambiguous and unsolicited statement of his or her status. Carrying literature pertaining to HIV/AIDS or related materials should not cause questioning regarding HIV status.
"However, discovery of medications used to treat HIV illness may result in questioning and a referral for a medical examination. As a result, some travellers carry their HIV-related medication in unmarked containers. A written prescription pertaining to the medication, however, should be carried in order to comply with US customs laws.

"If an individual with HIV is identified at the border, however, the BCIS has the authority to detain the individual indefinitely, without any right to release on bail. The individual has no right to counsel and may not be permitted to communicate with others who may be able to help the individual."5
Since 69% of US visits in the Brighton study were for tourism - which, according the latest INS factsheet6 is not a valid reason to be granted an HIV visa waiver - many (43.4%) were concerned that they would be denied a visa if they did declare their status.
However, the media often report conflicting and confusing (mis)information regarding who exactly is eligible for the HIV waiver, including this article from The Guardian two years ago. "Inadmissibility because of HIV/AIDS 'is routinely waived', a [US Embassy] spokesman said. 'People are given visas and the waiver many times and do travel on holidays, business and as students. It is a public health issue. In some cases it is a financial concern as well. It is not saying there is anything wrong with the person.'"8

Inadequate insurance
Despite the fact that 62% (n=215) of all respondents were aware that an HIV waiver was required, more than two-thirds (n=88) of all those who travelled to the US did so without adequate HIV medical insurance. This is not only risky, it is also another reason that the US says the HIV travel ban is in place: to make sure that foreigners do not place undue stress upon the US public health system.
Indeed, according to Section 212(a)(1)(A)(i) of the Immigration and Nationality Act: "The applicant must demonstrate that he or she is not currently afflicted with symptoms of the disease; there are sufficient assets, such as insurance, that would cover any medical care that might be required in the event of illness while in the United States; the proposed visit to the United States is for 30 days or less; and that the visit will not pose a danger to public health in the United States."9
Even though NAM, THT, Positive Nation and other HIV information resources make information available that explains that HIV-specific travel insurance is readily available for those who require it, Dr. Churchill speculates that "few people want to disclose their HIV status to an insurance company. Or it could be as simple as: 'I just want to have a holiday, I don't want to have to think about all this stuff.'"

A blunt instrument
Although one of the reasons for the US HIV ban is to control and monitor HIV-positive people entering the country, of the 135 who travelled to the US, only two (1.5%) actually travelled with an HIV waiver: 98.5% entered the country without the US knowing their HIV status. The most common reason (83%) given for not applying for an HIV waiver concerned disclosure to both the US and travelling companions.
"They think this law stops people with HIV from coming in unless they have a special waiver, and this is not the case," says THT's Kirk. "People keep coming in. It's a fairly blunt instrument and it's not working."

Ironically, if the law is there to prevent onwards transmission of HIV from foreign visitors, by forcing a significant minority into treatment interruptions - which invariably leads to a rise in viral load and therefore, theoretically, a rise in the likelihood of transmission - it is counterproductive.
" I don't think they've thought it through," comments THT's Kirk.

Please, Mr Postman
The most surprising conclusion of the Brighton study was that those people who took up the option of mailing their drugs to the US were more likely to stop treatment than those who chose to carry their drugs with them.
This was because of the 12 people who attempted to mail their drugs ahead of time, only seven were successful (42%). This compares with 62/83 (75%) of those who took their drugs with them.
Of the five who were unsuccessful, two reported that their drugs did not reach the USA (most likely prevented from entering by US customs); one reported that their drugs arrived late; and a further two found that they were unable to mail their drugs at all. Since 9/11 the Post Office and courier firms now require a detailed description of the contents of any package sent to the US, with full details of the sender as well as the addressee. This makes the sending of antiretrovirals anonymously impossible, and once the sender includes their details, the same fears of discovery by US officials would then apply.
Consequently, Dr. Churchill advises "to take enough medication with you to cover delays, as well as a letter from your doctor that doesn't mention HIV but does say that you need to be on these medications."

And if you are thinking of stopping your medications when travelling to the US - it is imperative that you consult with either your HIV clinician or pharmacist before doing so, otherwise you run the risk of acquiring new or further resistance that could have significant future health risks. Remember also that if you do stop HAART that you may feel ill during your trip, and that you may also be more infectious.

US Visitor's Ban Timeline
1987 President Reagan and Congress add AIDS to the list of "dangerous, contagious diseases for excluding persons from the United States." Senator Jesse Helms' "Helms amendment" adds HIV to the exclusion list
1989 Dutch HIV-prevention expert Hans Paul Verhoef jailed for four days in Minneapolis en route to an AIDS meeting in San Francisco, after AZT discovered in his suitcase.
1990 Mass boycott of Sixth International AIDS Conference in San Francisco; thousands demonstrate.
1992 International AIDS Conference moves from Boston to Amsterdam; Clinton campaign promises end to the ban by executive order.
1993 Congress adds amended to NIH Reauthorization Act adding HIV to the list of "communicable diseases for excluding people from the United States." Clinton signs the bill, making the policy law.
2001 9/11 results increased security and bag searches, increasing concerns that HIV meds would be found.
2002 THT launches 'End The Ban' campaign.

HIV+ tourists unwelcome here
  • Armenia

  • Bangladesh

  • Brunei

  • Iraq

  • Libya

  • Moldavia

  • Oman

  • Qatar

  • Russian Federation

  • Salomon Islands

  • Saudi Arabia

  • Sri Lanka

  • South Korea

  • Sudan

  • USA


References
1. see http://www.aidsnet.ch/modules.php?name=Content&pa=list_pages_categories&cid=5
2. see http://www.advocacyonline.net/eSite/tht/content_camp_end.jsp
3. Ponnusamy K et al. A study of knowledge, attitudes and health outcomes in HIV positive patients following travel to the United States of America. 9th EACS Warsaw, abstract 10.1/2, 2003.
4. see http://www.bhiva.org/guidelines/2003/hiv/index.html
5. see http://www.aidsandthelaw.com/issues/entry%20to%20US.htm
6. HIV Infection: Inadmissibility and Waiver Policies, US Department of Justice July 10, 1998 see http://uscis.gov/graphics/publicaffairs/factsheets/HIVfs.htm
7.Boseley S. Drive to end US curb on HIV visitors, The Guardian March 5, 2002.
8 INA 1996 see http://www.immigration-usa.com/ina_96_title_2.html