Immunizations for HIV-Infected Adults and Adolescents

Background

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.

Table 1. Vaccine Recommendations
Vaccine TypeRecommendation

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
  • Recommended for all.
  • If CD4 count is <200 cells/µL, may be less effective; consider revaccination when CD4 count increases in response to ART.
  • Two types of pneumococcal vaccine; both should be given, as follows.
Pneumococcal (polysaccharide) (PPV23)
  • 1 dose as soon as possible after HIV diagnosis (or PCV13 may be given first, see below); revaccinate 5 years after initial vaccination.
  • For those who received 1-2 doses of PPV23 before age 65, repeat at age ≥65 if ≥5 years since their previous dose.
  • PPV23 should not be given <8 weeks after PPV13 (see below).
Pneumococcal 13-valent conjugate (PPV13)
  • 1 dose recommended for all HIV-infected adults; timing varies according to whether PPV23 has been given:
  • No previous pneumococcal vaccination:
  • 1 dose PCV13 followed by PPV23 ≥8 weeks after PCV13.
    (If CD4 <200 cells/µL, PPV23 can be offered ≥8 weeks after PCV13 or can await increase of CD4 to >200 cells/µL.)
  • Previous PPV23 vaccination:
  • 1 dose of PCV13, given ≥1 year after last receipt of PPV23.
Hepatitis A Virus (HAV)
  • Recommended, for persons with chronic liver disease, injection drug users, men who have sex with men, international travelers, and hemophiliacs. Consider for all, unless there is serologic evidence of previous disease.
  • Serologic response (HAV IgG Ab) should be checked 1 month after completion of series, and nonresponders should be revaccinated.
  • 2 doses (Havrix: 0, 6-12 months; Vaqta: 0, 6-18 months).
Hepatitis B Virus (HBV)
  • Recommended for all, unless there is evidence of immunity (HBV surface Ab+) or active HBV infection (HBV surface Ag+, or HBV core Ab+ and evidence of HBV activity).
  • Many experts recommend giving a high dose of HBV vaccine (40 mcg), as is standard for hemodialysis patients; this may improve immunologic response in HIV-infected patients.
  • Most HIV-infected patients with isolated HBV core Ab+ (without HBV viremia) are not immune and should receive a complete series of HBV vaccine.
  • Anti-HBV surface Ab titers should be checked 1 month after completion of vaccine series. Patients whose titer level is ≤10 IU/mL should be revaccinated.
  • Standard dosing schedule is 3 doses (0, 1, and 6 months). If 40 mcg is given, the recommended schedule is 3 doses of Recombivax HB at 0, 1, and 6 months or 4 doses of Engerix-B at 0, 1, 2, and 6 months.
Influenza (inactivated vaccine)
  • Recommended (yearly).
  • Vaccination is most effective among persons with CD4 counts of >100 cells/µL and HIV RNA of <30,000 copies/mL.
  • In patients with advanced disease and low CD4 cell counts, inactivated vaccine may not produce protective antibodies. A second dose of vaccine does not improve response in these patients.
  • Live, attenuated cold-adapted vaccine (LAIV, FluMist) is not recommended for use in patients with HIV infection as the efficacy of the vaccine in this population has not been evaluated.
  • Close contacts of severely immunocompromised persons (including household members and health care personnel) should not receive live, attenuated influenza vaccine.
Tetanus, Diphtheria (Td); Tetanus, Diphtheria, Pertussis (Tdap)
  • Recommended (booster is recommended every 10 years in adults; or, if potential exposure [wound], after 5 years).
  • To protect against pertussis, substitute single dose of Tdap for Td booster in all patients aged 19-65 who have not received Tdap previously.
Measles, Mumps, Rubella (MMR)
  • Live vaccine is contraindicated for use in patients with severe immunosuppression (CD4 count of <200 cells/µL).
  • Recommended for all nonimmune persons with CD4 counts of ≥200 cells/µL.
Varicella-Zoster (VZV): Varicella vaccine (primary immunization)
  • Two doses (0, 3 months).
  • Live vaccine; contraindicated for use in patients with severe immunosuppression (CD4 count of <200 cells/µL).
  • Consider for HIV-infected, VZV-seronegative persons with CD4 counts of ≥200 cells/µL.
  • If vaccination results in infection with attenuated virus, treat with acyclovir.
  • Transmission of vaccine virus from vaccine recipients to susceptible individuals is possible; vaccine recipients should avoid close contact with high-risk susceptible individuals for 6 weeks after vaccination.
Varicella-Zoster (VZV): Zoster vaccine
  • One dose.
  • Live vaccine; contraindicated in persons with AIDS or other clinical manifestations of HIV infection.
  • Consider for select patients aged >50 with CD4 counts of >200 cells/µL and with evidence of varicella immunity (if no evidence of varicella immunity, give primary varicella vaccination). Limited data show safety and immunogenicity in this group.
  • Transmission of vaccine virus to susceptible contacts is possible.
Human Papillomavirus (HPV)
  • Two vaccines:
  • Gardasil includes HPV strains 16 and 18 (oncogenic) and 6 and 11 (wart causing); approved for use in women and men.
  • Cervarix: includes HPV strains 16 and 18; approved for use in women.
  • Gardasil or Cervarix recommended for females aged 9-26.
  • Gardasil vaccine recommended for males aged 9-26.
  • Not contraindicated for use in HIV-infected individuals; limited data on efficacy; may be less effective if CD4 count is <200 cells/µL.
Meningococcal
  • Two doses (0, ≥8 weeks).
  • Recommended if risk factor is present (e.g., college freshmen living in dormitory, military recruits, asplenia, complement component deficiency, travel to or residence in area with outbreaks,* occupational exposure).

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.

References

  • 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.