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 (e.g. rabies, tick-borne encephalitis, HAV/HBV) and consider antibody titres to assess their effectiveness if vaccinated at CD4 count < 200 cells/μL 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 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. Administer immunoglobulins if exposed and not yet vaccinated
    • Oral live typhoid
      • Preferred if CD4 count > 200 cells/μL (> 14%). Contraindicated if CD4 count < 200 cells/μL (14%): then give inactivated parenteral polysaccharide vaccine

 

 Infection Vaccination rationale in PLWH Comment
Influenza Virus Higher rate of pneumonia. Explicitly recommended in all PLWH 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 all PLWH 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) 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 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 (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. Vaccination against Meningococcus serotype B according to national Guidelines
Streptococcus pneumoniae Higher rate and severity of invasive disease. Vaccine explicitly recommended for all PLWH

One dose of conjugated(iii) 13-valent vaccine (PCV-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 PCV-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, 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 q 10 years
Rabies  

For PLWH with CD4 count < 200 cells/μL or unsuppressed viremia consid- er pre-exposure vaccination with 3 doses (0, 7, 28 days) and titre control 14 days later. In case of exposure: full post-exposure prophylaxis including rabies immunoglobulins (RIG). If pre-exposure rabies vaccination administered when CD4 > 200 cells/μL: Post-exposure prophylaxis as for immunocompetent (one dose day 0 and day 3, without RIG)
Severe Acute Respiratory Syndrome 2
(SARS-CoV-2)		 A higher prevalence of poor socio-economic circumstances and specific co-morbidities in PLWH (e.g. obesity, hypertension, CVD, DM) may increase the risk of acquiring SARS-CoV-2 infection and/or progressing to severe COVID-19 compared to the general population

In a pandemic situation, vaccinate irrespective of CD4 count and HIV-VL according to national Guidelines

 

  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