- Section 2: Testing and Assessment
- Initial History
- Initial Physical Examination
- Initial and Interim Laboratory and Other Tests
- Interim History and Physical Examination
- HIV Classification: CDC and WHO Staging Systems
- CD4 and Viral Load Monitoring
- Risk of HIV Progression/Indications for ART
- Early HIV Infection
- Expedited HIV Testing
- Resistance Testing
- Karnofsky Performance Scale
- Occupational Postexposure Prophylaxis
- Nonoccupational Postexposure Prophylaxis
- Preventing HIV Transmission/Prevention with Positives
- Immunizations for HIV-Infected Adults and Adolescents
- Preventing Exposure to Opportunistic and Other Infections
- Opportunistic Infection Prophylaxis
- Latent Tuberculosis Infection
- Smoking Cessation
- Abnormalities of Body-Fat Distribution
- Insulin Resistance, Hyperglycemia, and Diabetes on Antiretroviral Therapy
- Coronary Heart Disease Risk
- Renal Disease
- Immune Reconstitution Inflammatory Syndrome
- Anal Dysplasia
- Candidiasis, Oral and Esophageal
- Candidiasis, Vulvovaginal
- Cervical Dysplasia
- Cryptococcal Disease
- Cytomegalovirus Disease
- Gonorrhea and Chlamydia
- Hepatitis B Infection
- Hepatitis C Infection
- Herpes Simplex, Mucocutaneous
- Herpes Zoster/Shingles
- Kaposi Sarcoma
- Molluscum Contagiosum
- Mycobacterium avium Complex Disease
- Mycobacterium tuberculosis
- Pelvic Inflammatory Disease
- Pneumocystis Pneumonia
- Progressive Multifocal Leukoencephalopathy
- Seborrheic Dermatitis
Immunizations for HIV-Infected Adults and Adolescents
Publish date: April 2014
Immunocompromised individuals are at higher risk of acquiring many types of infections compared with immunocompetent people. Although HIV-infected persons could benefit greatly from immunization against preventable infections, little specific research on the effectiveness of immunizations in this population has been completed. In general, vaccines have better efficacy in HIV-infected patients when immune function is relatively well preserved, notably when the CD4 count is >200 cells/µL. Persons with advanced immunodeficiency may have an impaired humoral response, and may not respond to vaccines, or they may require supplemental doses to develop serologic evidence of protection. If possible, vaccines should be administered before the CD4 count decreases to <200 cells/µL; if given when the CD4 count is <200 cells/µL, consideration should be given to repeating the vaccination when the CD4 count increases to >200-300 cells/µL (unless there is evidence of immunity).
Live vaccines generally should not be administered to individuals with HIV infection, particularly those with advanced immunodeficiency, unless the anticipated benefits of vaccination clearly outweigh the risks.
Administration of vaccines can be associated with a transient rise in plasma HIV RNA.
Recommendations about vaccination for patients with HIV infection are presented in Table 1.
Abbreviations: Ab = antibody; Ag = antigen; ART = antiretroviral therapy
* In 2012, the New York City Department of Health and Mental Hygiene reported ongoing outbreak of meningococcal meningitis in men who have sex with men (MSM) and recommended vaccination for those with recent or future exposure risk. Many health departments in other areas have recommended vaccination of MSM, including HIV-infected MSM, who recently had or expect to have close contact with a man who is known to be, or could potentially be, from New York City.
|Pneumococcal (polysaccharide) (PPV23)|
|Pneumococcal 13-valent conjugate (PPV13)|
|Hepatitis A Virus (HAV)|
|Hepatitis B Virus (HBV)|
|Influenza (inactivated vaccine)|
|Tetanus, Diphtheria (Td); Tetanus, Diphtheria, Pertussis (Tdap)|
|Measles, Mumps, Rubella (MMR)|
|Varicella-Zoster (VZV): Varicella vaccine (primary immunization)|
|Varicella-Zoster (VZV): Zoster vaccine|
|Human Papillomavirus (HPV)|
Immunizations for HIV-Infected Patients Traveling to Developing Countries
Routine vaccinations should be reviewed and updated before travel. All patients traveling to other countries should be evaluated for both routine and destination-specific immunizations and prophylaxes. Inactivated (killed) and recombinant vaccines (e.g., diphtheria-tetanus, rabies, hepatitis A, hepatitis B, Japanese encephalitis) should be used for HIV-infected persons just as they would be used for HIV-uninfected persons anticipating travel. For further information, see the U.S. Centers for Disease Control and Prevention (CDC) webpage. Recommendations specific to HIV-infected travelers are located in "The Immunocompromised Traveler" under the section called "Advising Travelers with Special Needs." Select the "Traveler's Health" option for regional travel documents and information on outbreaks.
Decision making about immunization for the HIV-infected traveler should take into consideration the traveler's current CD4 cell count, history of AIDS-defining illness, and clinical manifestations of symptomatic HIV. In the CDC recommendations, asymptomatic HIV-infected persons with CD4 counts of 200-500 cells/µL are considered to have limited immune deficits, whereas patients with CD4 counts of >500 cells/µL are considered to have no immunologic compromise. For patients taking antiretroviral therapy, current CD4 counts rather than nadir counts should be used in deciding about immunizations. The CDC recommends that newly diagnosed, treatment-naive patients with CD4 counts of <200 cells/µL delay travel until after immunologic reconstitution with antiretrovirals to minimize risk of infection and immune reconstitution illness during travel.
The following should be noted about specific vaccinations:
- Inactivated (killed), enhanced-potency polio and typhoid vaccines should be given instead of the live, attenuated forms. In adults aged >18, vaccinate 8 weeks before travel to allow time for the initial 2 doses of polio vaccine.
- Measles or measles, mumps, and rubella (MMR; omit if patient has evidence of immunity) should not be given to severely immunocompromised patients. Instead, immune globulin should be given to measles-susceptible, severely immunocompromised persons traveling to measles-endemic countries.
- Yellow fever vaccine is a live-virus vaccine with uncertain safety and efficacy for HIV-infected persons, and it should be avoided if possible. Travelers with asymptomatic HIV infection and relatively high CD4 counts who cannot avoid potential exposure to yellow fever should be offered the choice of vaccination. If travel to a zone with yellow fever is necessary and vaccination is not administered, patients should be advised about the risk of yellow fever, instructed about avoiding the bites of vector mosquitoes, and provided with a vaccination waiver letter (though travelers should be warned that not all countries accept waiver letters).
- The influenza season in the Southern Hemisphere is April through September, but in the tropics, influenza is a year-round infection. Immunocompromised patients should be protected on the basis of influenza risk at the destination. HIV-infected patients should not be given live intranasal influenza vaccine.
- Aberg JA, Gallant JE, Ghanem KG, et al.; HIV Medicine Association of the Infectious Diseases Society of America. Primary Care Guidelines for the Management of Persons Infected With HIV: 2013 Update by the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis. 2014 Jan;58(1):e1-e34.
- ACIP Adult Immunization Work Group, Bridges CB, Woods L, et al.; Centers for Disease Control and Prevention. Advisory Committee on Immunization Practices (ACIP) recommended immunization schedule for adults aged 19 years and older - United States, 2013. MMWR Surveill Summ. 2013 Feb 1;62 Suppl 1:9-19.
- Benson C, Hua L, Andersen J, et al. Zostavax is generally safe and immunogenic in HIV+ adults virologically suppressed on ART: results of a phase 2, randomized, double-blind, placebo-controlled trial. In: Program and abstracts of the 12th Conference on Retroviruses and Opportunistic Infections; March 5-8, 2012; Seattle. Abstract 96.
- Centers for Disease Control and Prevention. The Immunocompromised Traveler. In: CDC Health Information for International Travel. Atlanta: U.S. Department of Health and Human Services, Public Health Service; 2012. Accessed December 1, 2013.
- Kroon FP, van Dissel JT, de Jong JC, et al. Antibody response after influenza vaccination in HIV-infected individuals: a consecutive 3-year study. Vaccine. 2000 Jul 1;18(26):3040-9.
- Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. Accessed December 1, 2013.
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HRSA HAB Performance Measures
- Influenza Immunization
Percentage of patients, aged 6 months and older seen for a visit between October 1 and March 31, who received an influenza immunization OR who reported previous receipt of an influenza immunization. Learn More
- Hepatitis B Vaccination
Percentage of patients with a diagnosis of HIV who completed the vaccination series for hepatitis B. Learn More
- Pneumococcal Vaccination
Percentage of patients with a diagnosis of HIV who ever received pneumococcal vaccine. Learn More
Abbreviations for Dosing Terminology
- twice daily
- twice weekly
- intramuscular (injection), intramuscularly
- intravenous (injection), intravenously
- oral, orally
- Q2H, Q4H, etc.
- every 2 hours, every 4 hours, etc.
- every morning
- once daily
- every hour
- every night at bedtime
- four times daily
- every other day
- every evening
- three times daily
- three times weekly