Clinical Guide > Maintenance and Prevention > Immunizations

# Immunizations for HIV-Infected Adults and Adolescents

January 2011

### Chapter Contents

      - Background
      - Immunizations for HIV-Infected Patients Traveling to Developing Countries
      - ReferencesTable 1. Vaccine RecommendationsHRSA HAB Core Clinical Performance MeasuresBackground
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 RecommendationsVaccine TypeRecommendationAbbreviations: Ab = antibody; Ag = antigen; ART = antiretroviral therapyPneumococcal (polysaccharide)- Recommended for all; consider revaccination 5 years after initial vaccination; some experts recommend vaccination every 5 years.
- If CD4 count is <200 cells/µL, may be less effective; consider revaccination when CD4 count increases in response to ART.
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.
- Two doses (0, 6-12 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 three doses (0, 1, and 6 months). If 40 mcg is given, the recommended schedule is three doses of Recombivax HB at 0, 1, and 6 months or four 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 contraindicated for use in patients with HIV infection.
- Close contacts of severely immunocompromised persons (including household members and health care personnel) should not receive live, attenuated influenza vaccine.
H1N1 Influenza (inactivated vaccine) - Recommended (inactivated vaccine), though not thoroughly studied in HIV-infected persons (see Centers for Disease Control and Prevention [CDC] guidelines for up-to-date recommendations).
- The live, attenuated nasal vaccine is not recommended.
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 ≥200 cells/µL.
Varicella-Zoster (VZV)- Live vaccine is contraindicated for use in patients with severe immunosuppression (CD4 count of <200 cells/µL).
- Consider for HIV-infected, VZV-seronegative persons with CD4 counts ≥200 cells/µL.
- If vaccination results in infection with attenuated virus, treat with acyclovir.
- Susceptible household contacts of susceptible HIV-infected individuals should be vaccinated.
- Avoid exposure to VZV, if possible. If someone without immunity to VZV is exposed to VZV, administer varicella-zoster immune globulin (VZIG) as soon as possible (but within 96 hours).
- Two doses (0, 3 months).
Human Papillomavirus (HPV)- Two vaccines:    - Gardisil includes HPV strains 16 and 18 (oncogenic) and 6 and11 (wart causing)
  - Cervarix: includes HPV strains 16 and 18
- Recommended for females aged 9-26.
- Gardasil vaccine approved for males aged 9-26.
- Not contraindicated for use in HIV-infected individuals, though no data are available regarding use in this group.
- No data on efficacy in preventing anal dysplasia.
Meningococcal- Recommended if risk factor is present (e.g., college freshmen living in dormitory, military recruits, asplenia, complement component deficiency, travel to or residence in endemic area, 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 "Special Needs Travelers." 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 an 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 two 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- Advisory Committee on Immunization Practices.  Recommended adult immunization schedule: United States, 2010. Ann Intern Med . 2010 Jan 5;152(1):36-9.
- Centers for Disease Control and Prevention.  Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents: Recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America . April 10, 2009.
- Centers for Disease Control and Prevention.  The Immunocompromised Traveler . In:  CDC Health Information for International Travel 2010 . Atlanta: U.S. Department of Health and Human Services, Public Health Service; 2009. 
- Fiore AE, Shay DK, Broder K, et al.; Centers for Disease Control and Prevention.  Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009 . MMWR Recomm Rep. 2009 Jul 31;58(RR-8):1-52.
- 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.
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention. Use of  Influenza A (H1N1) 2009 Monovalent Vaccine Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009 . MMWR Recomm Rep. 2009 Aug 28;58(RR-10):1-8.
**HRSA HAB Core Clinical Performance MeasuresPercentage of clients with HIV infection who completed the **vaccination series for hepatitis B** (Group 2) Percentage of clients with HIV infection who ever received **pneumococcal vaccine** (Group 3) Percentage of clients with HIV infection who have received **influenza vaccination** in the measurement period (Group 3)**