Vaccination

  • Vaccinate according to national guidelines for healthy population, preferably after having achieved suppressed viraemia and immune reconstitution (CD4 count > 200 cells/μL)
  • Consider repeating vaccinations performed at CD4 count < 200 cells/μL (< 14%) or unsuppressed viraemia once adequate immune reconstitution is achieved (HIV-VL undetectable and CD4 count > 200 cells/μL)
  • As vaccine responses may be significantly lower in PLWH (i.e. lower seroconversion rates, faster titer decline), do not use rapid schedules and consider antibody titers to assess their effectiveness if vaccinated at CD4 count < 200 cells/μL or unsuppressed viremia (e.g. rabies, tick-borne encephalitis, HAV, meningococci)
  • Avoid polysaccharide vaccination
  • For background data, see http://www.bhiva.org/vaccination-guidelines.aspx
  • 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 (14%) and/or AIDS. Impaired protection after vaccination with unsuppressed viraemia
    • Oral live typhoid
      • Contraindicated if CD4 count < 200 cells/μL (14%): give inactivated parenteral polysaccharide vaccine. Preferred if CD4 count > 200 cells/μL (> 14%)

 

 Infection Vaccination rationale in PLWH Comment
Influenza Virus Higher rate of pneumonia. Explicitly recommended in all PLWH Yearly
Human Papilloma Virus (HPV) Shared risk with HIV of contracting infection. Higher rate of cervical and anal cancer

Vaccinate all PLWH with 3 doses between ages 9 and 40 (health insurance coverage differs by country according to age, sex, sexual orientation). Use 9-valent vaccine if available. Persons treated for high grade cervical dysplasia could benefit from a full course vaccination for secondary prevention
Hepatitis B Virus (HBV) Shared risk with HIV of contracting infection. HIV accelerates liver disease progression

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) in particular with low CD4 count and high HIV-VL. See Clinical Management and Treatment of Viral Hepatitis Co-infections in PLWH
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 PLWH with high risk. Weaker immune response expected with HAV/HBV co-vaccine. See Clinical Management and Treatment of Viral Hepatitis Co-infections in PLWH
Neisseria meningitidis According to risk profile (travel, close contact with children, MSM)

Use conjugated(iii) 4-valent vaccine (2 doses 1-2 months apart) if available. Booster every five years if exposure continues. Polysaccharide vaccine not recommended anymore
Streptococcus pneumoniae Higher rate and severity of invasive disease. Vaccine explicitly recommended
for all PLWH

One dose of conjugated(iii) 13-valent vaccine (CPV-13) for all PLWH, also if pre-vaccinated with PPV-23 polysaccharide vaccine. No general recommendation for any booster dose. Some national guidelines consider one dose of PPV-23 at least 2 months after CPV-13 for all PLWH
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 consider adjuvant sub-unit vaccine rather than 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 q 10 years
Rabies  

For PLWH with CD4 count < 200 cells/μL or unsuppressed viremia consider pre-exposure vaccination with 3 doses (0, 7, 28 days) and titer control 14 days later as well as post-exposure immunoglobulins for all non-vaccinated

Notes:

  1. Administer live vaccines simultaneously or with an interval of 4 weeks
  2. In case of non-response, ART should contain TDF or TAF
  3. Conjugated vaccines are more immunogenic, induce memory cells, respond to boosting and reduce mucosal colonisation