4.4 Immunisation in Persons with HIV

Vaccinate according to national guidelines for healthy population, preferably after having achieved suppressed viraemia and immune reconstitution (CD4 count ≥200 cells/μL or ≥15%)
Consider repeating vaccinations performed at CD4 count <200 cells μL (or <15%) or unsuppressed viraemia once adequate immune reconstitution is achieved (HIV VL undetectable and CD4 count ≥200 cells/μL or ≥15%
As vaccine responses may be significantly lower in persons with HIV (i.e. lower seroconversion rates, faster titre decline), do not use rapid schedules (e.g. rabies, tick-borne encephalitis, HAV/HBV) and consider antibody titres to assess their effectiveness if vaccinated at CD4 count <200 cells/μL (<15%) or unsuppressed viremia (e.g. rabies, tick-borne encephalitis, HAV, meningococci). Be attentive to observe boosters and all post-exposure measures (particularly after potential rabies exposure)
Avoid polysaccharide vaccination
For background data, see www.bhiva.org/vaccination-guidelines.aspx and www.cdc.gov/vaccines/schedules/downloads/adult/adult-combinedschedule.pdf
For attenuated live vaccines⁽ⁱ⁾(in addition to restrictions for general population):
- *Varicella, measles, mumps, rubella, yellow fever
  Contraindicated if CD4 count <200 cells/μL (<15%) and/or AIDS. Impaired protection after vaccination with unsuppressed viraemia. Administer immunoglobulins if exposed and not yet vaccinated
- Oral live typhoid
  Preferred if CD4 count ≥200 cells/μL (≥15%). Contraindicated if CD4 count < 200 cells/μL (<15%): then give inactivated parenteral polysaccharide vaccine
- Mpox (Jynneos, Imvamune^® or Imvanex^®)
  This live but attenuated non-replicating modified vaccinia Ankara (MVA) strain vaccine is safe in persons with HIV, although effectiveness may be lower if CD4 count <200 cells/μL (<15%) and/or people living with unsuppressed HIV

Infection	Vaccination rationale	Comment
Influenza Virus	Higher rate of pneumonia. Explicitly recommended in all persons with HIV	Yearly, use 4-valent vaccine if available
Human Papilloma Virus (HPV)	Shared risk with HIV of contracting infection. Higher rate of cervical and anal cancer	Vaccinate with 3 doses between ages 9 and 45 (health insurance coverage differs by country according to age, sex, sexual orientation). Use 9-valent vaccine if available. Persons treated for high grade dysplasia could benefit from a full course vaccination for secondary prevention
Hepatitis B Virus (HBV)	Shared risk with HIV of contracting infection. Untreated HIV accelerates progression of liver disease	Vaccinate if seronegative. Repeat doses until anti-HBs antibodies ≥ 10 IU/L / ≥ 100 IU/L according to national Guidelines. In order to reach ≥ 100 IU/L in non-responders repeat 3 doses if anti-HBs < 10 IU/L, 1 dose if anti-HBs < 100 IU;(ii) consider double dose (40 μg) or use more immunogenic vaccines in particular with low CD4 count and high HIV VL. No benefit for intradermal application. See Clinical Management and Treatment of Viral Hepatitis Co-infections
Hepatitis A Virus (HAV)	According to risk profile (travel, close contact with children, MSM, IVDU, active hepatitis B or C infection, chronic liver disease)	Vaccinate if seronegative. Consider checking antibody titres in persons at high risk. Weaker immune response expected with HAV/HBV co-vaccine. See Clinical Management and Treatment of Viral Hepatitis Co-infections
Neisseria meningitidis	According to risk profile (travel, close contact with children, MSM)	Use conjugated⁽ⁱⁱⁱ⁾ 4-valent vaccine (for serotypes A, C, W-135, Y; 2 doses 1-2 months apart) if available. Booster every five years if exposure continues. Polysaccharide vaccine no longer recommended. Vaccinate against Meningococcus serotype B according to national guidelines
Streptococcus pneumoniae	Higher rate and severity of invasive disease. Vaccine explicitly recommended for all persons with HIV	One dose of a conjugated vaccine: PCV-13, PCV-15 or PCV-20a for all persons according to availability and national guidelines, also if pre-vaccinated with PPV-23 polysaccharide vaccine. For patients vaccinated with PCV-13 or PCV-15, one dose of PPV-23 at least 2 months after the conjugate vaccine may be considered in some national guidelines for all persons with HIV
Varicella Zoster Virus (VZV)	Higher rate and severity of both chickenpox and zoster	Perform serology if exposure history negative. Vaccinate if seronegative. For contraindications, see*. To prevent shingles, preferably use adjuvant recombinant sub-unit vaccine over live-attenuated vaccine according to national guidelines
Yellow Fever Virus	Mandatory for travel to selected countries (provide exemption letter if no true risk of exposure)	Contraindicated if past or current haematological neoplasia or thymus affection (thymoma, resection/radiation) For other contraindications, see*. Booster every 10 years
Rabies		If pre-exposure rabies vaccination is administered in persons with CD4 ≥ 200 cells/μL, 2-dose (days 0 and 7) IM schedule is recommended. For persons with CD4 count <200 cells/μL or detectable viremia, consider pre-exposure vaccination with 3 doses (0, 7, 21 or 28 days) and antibody titre measurement 14 days later. In case of rabies postexposure prophylaxis (PEP) in unvaccinated persons, perform immediate wound cleaning, infiltration of human rabies immunoglobulin (HRIG) within and around the wound and days 0, 3, 7 and 14 IM administration of rabies vaccine in people with HIV with CD4≥200 cells/μL. In people with HIV with CD4 <200 cells/μL or detectable viremia, PEP should comprise a 5-dose vaccination regimen (days 0, 3, 7, 14, and 28), with one dose of HRIG and additional vaccine dose is recommended if rabies serology demonstrates inadequate titers during the follow-up (antibody levels <0.5 IU/mL). In vaccinated people with HIV, the PEP recommendation for a 2/3-dose vaccination series has not changed
Severe Acute Respiratory Syndrome 2 (SARS-CoV-2)	Low CD4 count and non-suppressed HIV VL may increase the risk of acquiring SARS-CoV-2 infection and/or progressing to severe COVID-19	All persons with HIV should be vaccinated according to the national guidelines irrespective of CD4 count and HIV VL. Advanced HIV infection (CD4 count < 200 cells/μL) and persons with detectable HIV viraemia have poorer humoral immune responses and are candidates for COVID-19 booster doses. COVID-19 vaccines must be updated with antigens from circulating SARS-CoV-2 variants. For the 2024-25 season, vaccination should be performed with vaccines targeting JN.1 or KP.2 variants.
Mpox, See Management of Mpox in persons with HIV	Mpox can be a life-threatening opportunistic infection in people with HIV with CD4 count <200 cells/μL (<15%) and/or detectable HIV viraemia	Two doses administered 28 days (4 weeks) apart by subcutaneous (0.5 mL) route. Intradermal route also effective using one fifth of the standard dose. Primary mpox vaccination should be offered to all people using HIV PrEP and people with HIV at high-risk for mpox exposure(iv). In case of vaccine shortage, people with HIV with advanced disease (CD4 T-cells<350/uL) or detectable HIV viraemia should be prioritised, according to the WHO and CDC guidelines. Post-exposure prophylaxis with mpox vaccination should be given as soon as possible and ideally within four days of exposure. Administration 4 to 14 days after exposure may still provide some protection. People with HIV with advanced disease (CD4 T-cells<350/uL or detectable HIV viraemia should be prioritised for post-exposure vaccination (if available) according to local and international WHO, CDC guidelines

Infection

Vaccination rationale

Comment

Influenza Virus

Higher rate of pneumonia.

Explicitly recommended in all persons with HIV

Yearly, use 4-valent vaccine if available

Human Papilloma Virus (HPV)

Shared risk with HIV of contracting infection. Higher rate of cervical and anal cancer

Vaccinate with 3 doses between ages 9 and 45 (health insurance coverage differs by country according to age, sex, sexual orientation). Use 9-valent vaccine if available. Persons treated for high grade dysplasia could benefit from a full course vaccination for secondary prevention

Hepatitis B Virus (HBV)

Shared risk with HIV of contracting infection. Untreated HIV accelerates progression of liver disease

Vaccinate if seronegative. Repeat doses until anti-HBs antibodies ≥ 10 IU/L / ≥ 100 IU/L according to national Guidelines. In order to reach ≥ 100 IU/L in non-responders repeat 3 doses if anti-HBs < 10 IU/L, 1 dose if anti-HBs < 100 IU;(ii) consider double dose (40 μg) or use more immunogenic vaccines in particular with low CD4 count and high HIV VL. No benefit for intradermal application. See Clinical Management and Treatment of Viral Hepatitis Co-infections

Hepatitis A Virus (HAV)

According to risk profile (travel, close contact with children, MSM, IVDU, active hepatitis B or C infection, chronic liver disease)

Vaccinate if seronegative. Consider checking antibody titres in persons at high risk. Weaker immune response expected with HAV/HBV co-vaccine. See Clinical Management and Treatment of Viral Hepatitis Co-infections

Neisseria meningitidis

According to risk profile (travel, close contact with children, MSM)

Use conjugated⁽ⁱⁱⁱ⁾ 4-valent vaccine (for serotypes A, C, W-135, Y; 2 doses 1-2 months apart) if available. Booster every five years if exposure continues. Polysaccharide vaccine no longer recommended. Vaccinate against Meningococcus serotype B according to national guidelines

Streptococcus pneumoniae

Higher rate and severity of invasive disease. Vaccine explicitly recommended for all persons with HIV

One dose of a conjugated vaccine: PCV-13, PCV-15 or PCV-20a for all persons according to availability and national guidelines, also if pre-vaccinated with PPV-23 polysaccharide vaccine. For patients vaccinated with PCV-13 or PCV-15, one dose of PPV-23 at least 2 months after the conjugate vaccine may be considered in some national guidelines for all persons with HIV

Varicella Zoster Virus (VZV)

Higher rate and severity of both chickenpox and zoster

Perform serology if exposure history negative. Vaccinate if seronegative. For contraindications, see*. To prevent shingles, preferably use adjuvant recombinant sub-unit vaccine over live-attenuated vaccine according to national guidelines

Yellow Fever Virus

Mandatory for travel to selected countries (provide exemption letter if no true risk of exposure)

Contraindicated if past or current haematological neoplasia or thymus affection (thymoma, resection/radiation) For other contraindications, see*. Booster every 10 years

Rabies

If pre-exposure rabies vaccination is administered in persons with CD4 ≥ 200 cells/μL, 2-dose (days 0 and 7) IM schedule is recommended.
For persons with CD4 count <200 cells/μL or detectable viremia, consider pre-exposure vaccination with 3 doses (0, 7, 21 or 28 days) and antibody titre measurement 14 days later. In case of rabies postexposure prophylaxis (PEP) in unvaccinated persons, perform immediate wound cleaning, infiltration of human rabies immunoglobulin (HRIG) within and around the wound and days 0, 3, 7 and 14 IM administration of rabies vaccine in people with HIV with CD4≥200 cells/μL. In people with HIV with CD4 <200 cells/μL or detectable viremia, PEP should comprise a 5-dose vaccination regimen (days 0, 3, 7, 14, and 28), with one dose of HRIG and additional vaccine dose is recommended if rabies serology demonstrates inadequate titers during the follow-up (antibody levels <0.5 IU/mL). In vaccinated people with HIV, the PEP recommendation for a 2/3-dose vaccination series has not changed

Severe Acute Respiratory Syndrome 2
(SARS-CoV-2)

Low CD4 count and non-suppressed HIV VL may increase the risk of acquiring SARS-CoV-2 infection and/or progressing to severe COVID-19

All persons with HIV should be vaccinated according to the national guidelines irrespective of CD4 count and HIV VL. Advanced HIV infection (CD4 count < 200 cells/μL) and persons with detectable HIV viraemia have poorer humoral immune responses and are candidates for COVID-19 booster doses. COVID-19 vaccines must be updated with antigens from circulating SARS-CoV-2 variants. For the 2024-25 season, vaccination should be performed with vaccines targeting JN.1 or KP.2 variants.

Mpox, See Management of Mpox in persons with HIV

Mpox can be a life-threatening opportunistic infection in people with HIV with CD4 count <200 cells/μL (<15%) and/or detectable HIV viraemia

Two doses administered 28 days (4 weeks) apart by subcutaneous (0.5 mL) route. Intradermal route also effective using one fifth of the standard dose.
Primary mpox vaccination should be offered to all people using HIV PrEP and people with HIV at high-risk for mpox exposure(iv). In case of vaccine shortage, people with HIV with advanced disease (CD4 T-cells<350/uL) or detectable HIV viraemia should be prioritised, according to the WHO and CDC guidelines.
Post-exposure prophylaxis with mpox vaccination should be given as soon as possible and ideally within four days of exposure. Administration 4 to 14 days after exposure may still provide some protection. People with HIV with advanced disease (CD4 T-cells<350/uL or detectable HIV viraemia should be prioritised for post-exposure vaccination (if available) according to local and international WHO, CDC guidelines

Administer live vaccines simultaneously or with an interval of 4 weeks
In case of non-response, consider ART containing TDF or TAF
Conjugated vaccines are more immunogenic, induce memory cells, respond to boosting and reduce mucosal colonisation
Gay, bisexual, and other men who have sex with men, and transgender or nonbinary people (including adolescents who fall into any of the aforementioned categories) who in the past 6 months have had:
- A new diagnosis of one or more sexually transmitted diseases (e.g., chlamydia, gonorrhea, syphilis); or
- More than one sexual partner; or
- People who have had any of the following in the past 6 months:
• Sex at a commercial sex venue; or
• Sex in association with a large public event in a geographic area where mpox transmission is occurring; or
• Sexual partners of people with the above risks; or
• People with HIV or other causes of immunosuppression who have had recent or anticipate potential mpox exposure