Immunization Guidelines for HIV-infected Adults

Immunizations

Rationale and Background
Guidelines

Rationale and Background

Patients with HIV disease are at increased risk for a variety of infections that can potentially be prevented by using available vaccine preparations.
Immunizations should be given as early in the course of HIV disease as possible for optimal effect. Patients with relatively preserved immune function are more likely to have a favorable response to vaccine challenge than those who are significantly immunocompromised. Initiation of combination antiretroviral therapy in patients with advanced HIV disease may improve the immunologic response to vaccine preparations.

In general, live pathogen vaccines, such as measles, mumps, rubella (MMR) and varicella-zoster virus are avoided in HIV-infected adults with low CD4 cell counts. However, killed or inactivated vaccines are considered safe in all patients.

Influenza and other vaccine preparations have been shown to transiently stimulate HIV replication and increase the viral load. This phenomenon does not appear to have an impact on overall disease progression.

[Top]

Guidelines

Specific immunization recommendations are presented in Table 1. Pneumococcal vaccine should be administered to all HIV-infected patients with CD4 cell count > 200/mm3. Some experts recommend a booster dose five years after immunization. Hepatitis B immunization series should be given to patients who have a negative screening serologic test for this infection. Hepatitis A vaccine should be administered to men who have sex with men and to patients with chronic hepatitis C infection. Influenza vaccine is recommended by the Centers for Disease Control and Prevention. It is especially important in individuals with historical risk factors for exposure to the virus and the presence of conditions associated with increased morbidity from influenza infection. Routine use of hemophilus B vaccine is not recommended, but it should be administered in asplenic patients and in those with history of recurrent hemophilus infection.

Table 1. Immunizations in HIV-infected Adults
Vaccine Status Dose/Regimen Comments

Pneumococcal vaccine Recommended 0.5 ml IM Consider revaccination five years after initial dose.

Hepatitis B vaccine Recommended in selected settings; see comments Engerix B 20 ug or Recombivax HB 10 ug IM given at 0, 1, and 6 months Administer to patients without serologic evidence of past or present hepatitis B infection. Vaccinated patients with should be tested for HBsAb response after the third dose; nonresponders should receive booster injections.

Hepatitis A vaccine Recommended in selected settings; see comments 1 ml IM with revaccination in 6-12 months Administer to homosexual or bisexual men and to women who practice receptive anal intercourse. Serologic testing prior to vaccination is not necessary.

Hemophilus influenzae type B vaccine Consider in selected settings; see comments 0.5 ml IM Administer to asplenic patients and those with history of recurrent hemophilus infection.

Influenza vaccine Recommended in selected settings; see comments 0.5 ml IM annually Administer to patients at high risk for exposure to or morbidity from influenza. There is evidence that the vaccine may transiently promote HIV replication.

Tetanus toxoid Same as for patient without HIV infection Td 0.5 ml IM Td booster is recommended every 10 years.

Polio vaccine OPV contraindicated; eIPV if indicated 0.5 ml SC OPV has not proven harmful when given to asymptomatic HIV-infected patients, but eIPV is preferred.

[Table of Contents || Top]
Comments about these guidelines are welcome and can be sent to the author at hlibman@caregroup.harvard.edu

Vaccine	Status	Dose/Regimen	Comments
Pneumococcal vaccine	Recommended	0.5 ml IM	Consider revaccination five years after initial dose.
Hepatitis B vaccine	Recommended in selected settings; see comments	Engerix B 20 ug or Recombivax HB 10 ug IM given at 0, 1, and 6 months	Administer to patients without serologic evidence of past or present hepatitis B infection. Vaccinated patients with should be tested for HBsAb response after the third dose; nonresponders should receive booster injections.
Hepatitis A vaccine	Recommended in selected settings; see comments	1 ml IM with revaccination in 6-12 months	Administer to homosexual or bisexual men and to women who practice receptive anal intercourse. Serologic testing prior to vaccination is not necessary.
Hemophilus influenzae type B vaccine	Consider in selected settings; see comments	0.5 ml IM	Administer to asplenic patients and those with history of recurrent hemophilus infection.
Influenza vaccine	Recommended in selected settings; see comments	0.5 ml IM annually	Administer to patients at high risk for exposure to or morbidity from influenza. There is evidence that the vaccine may transiently promote HIV replication.
Tetanus toxoid	Same as for patient without HIV infection	Td 0.5 ml IM	Td booster is recommended every 10 years.
Polio vaccine	OPV contraindicated; eIPV if indicated	0.5 ml SC	OPV has not proven harmful when given to asymptomatic HIV-infected patients, but eIPV is preferred.