Clinical Manual > Health Maintenance > Immunizations

Immunizations for HIV-Infected Adults and Adolescents

July 2006

Chapter Contents

Background

Immunizations for HIV-Infected Patients Traveling to Developing Countries

References

Table 1. Vaccine Recommendations

Background

Immunocompromised individuals are at higher risk for 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 (see Table 1) 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.

Live vaccines generally should not be administered to those with HIV infection, particularly those with advanced immunodeficiency, unless the anticipated benefits of vaccination clearly outweigh possible risks.

Table 1 presents recommendations about vaccination for patients with HIV infection.

Table 1. Vaccine Recommendations

Vaccine Type	Recommendation
Key to abbreviations: ART = antiretroviral therapy; Ab = antibody; Ag = antigen. * HIV-infected persons with CD4 counts <200 cells/µL, history of an AIDS-defining illness, or clinical manifestations of symptomatic HIV are considered to have severe immunosuppression. Asymptomatic HIV-infected persons with CD4 counts of 200-500 cells/µL are considered to have limited immune deficits. ** HIV-negative susceptible household contacts (especially children) of HIV-infected susceptible patients should be vaccinated against VZV, so that they will not transmit VZV to the HIV-infected patient. HIV-infected susceptible patients should limit their contact with recently vaccinated children or adults for 12-14 days after vaccination.
Pneumococcal (polysaccharide)	Recommended for all; consider revaccination every 5 years. If CD4 count is <200 cells/µL, may be less effective; revaccinate when CD4 count increases in response to ART.
Hepatitis A Virus (HAV)	Recommended, for persons with chronic hepatitis C or hepatitis B, injection drug users, men who have sex with men, international travelers, and hemophiliacs. Consider for all, unless there is serologic evidence of previous disease. 2 doses (0, 6-12 months)
Hepatitis B Virus (HBV)	Recommended, unless there is evidence of immunity (HBV surface Ab+) or active hepatitis B infection (HBV surface Ag+, or HBV core Ab+ and evidence of HBV activity). 3 doses (0, 1-2, 4-6 months)
Influenza (inactivated vaccine)	Recommended (yearly) Vaccination is most effective among persons with CD4 count >100 cells/µL and HIV RNA <30,000 copies/mL. In patients with advanced disease and low CD4 cell count, inactivated vaccine may not produce protective antibodies. Live, attenuated cold-adapted vaccine (LAIV, FluMist) is contraindicated in patients with HIV infection.
Tetanus-Diphtheria	Recommended (booster is recommended every 10 years in adults; or, if injured, after 5 years)
Measles, Mumps, Rubella (MMR)	Recommended if indicated (eg, if contact with measles is likely through travel or other exposures). For live vaccine, use caution in those with low CD4 counts. Consider for all susceptible people who are not severely immunosuppressed.* Contraindicated in severe immunosuppression.
Varicella Zoster (VZV)**	Consider for asymptomatic patients with relatively high CD4 counts, if they have no history of chickenpox and no evidence of immunity or significant exposure. Avoid in patients with advanced immunosuppression. Avoid exposure to VZV, if possible. If someone without immunity to VZV is exposed to VZV, administer VZIG as soon as possible, at least within 96 hours.

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. Killed and recombinant vaccines (eg, 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 Centers for Disease Control and Prevention (CDC) Web page at http://www.cdc.gov/travel/ . 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.

Decisions 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 >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 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 years, vaccinate 8 weeks before travel to allow time for the initial 2 doses of polio vaccine.
Measles or measles-mumps-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 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.
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 according to influenza risk at the destination. HIV-infected patients should not be given live intranasal influenza vaccine.

References

Centers for Disease Control and Prevention. The Immunocompromised Traveler . In: Health Information for International Travel 2005-2006 . Atlanta: U.S. Department of Health and Human Services, Public Health Service, 2005. Available online at www.cdc.gov/travel/spec_needs.htm.

Centers for Disease Control and Prevention. Recommended adult immunization schedule, United States, October 2005-September 2006 . Accessed February 7, 2006. Available online at www.cdc.gov/nip/recs/adult-schedule.htm.

Centers for Disease Control and Prevention. Prevention and control of meningococcal disease: Recommendations of the Advisory Committee on Immunization Practices (ACIP) . MMWR Recomm Rep. 2005 May 27;54(RR-7):1-21.

Centers for Disease Control and Prevention. Prevention and control of influenza: Recommendations of the Advisory Committee on Immunization Practices (ACIP) . MMWR Recomm Rep. 2005 Jul 29;54(RR-8):1-40.

Centers for Disease Control and Prevention, National Institutes of Health, HIV Medicine Association/Infectious Diseases Society of America. Treating Opportunistic Infections Among HIV-Infected Adults and Adolescents . MMWR Recomm Rep. 2004 Dec 17; 53(RR15);1-112. Available online at aidsinfo.nih.gov/Guidelines/GuidelineDetail.aspx?GuidelineID=14. Accessed May 19, 2006.

Centers for Disease Control and Prevention. Prevention of hepatitis A through active or passive immunization . MMWR Recomm Rep. 1999 Oct 1;48(RR-12):1-37.

Fine AD, Bridges CB, De Guzman AM, et al. Influenza A among patients with human immunodeficiency virus: an outbreak of infection at a residential facility in New York City . Clin Infect Dis. 2001 Jun 15;32(12):1784-91.

Kirton C. Immunizations. In: Kirton C, ed. ANAC's Core Curriculum for HIV/AIDS Nursing, 2nd ed. Thousand Oaks, CA: Sage Publications; 2003:40-43.

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.

Sande MA, Eliopoulos GM, Moellering RC, et al. The Sanford Guide to HIV/AIDS Therapy, 14th ed . Hyde Park, VT: Antimicrobial Therapy, Inc.; 2005.

U.S. Public Health Service, Infectious Diseases Society of America. Guidelines for preventing opportunistic infections among HIV-infected persons -- 2002 . MMWR Recomm Rep. 2002 Jun 14;51(RR08);1-46. Available online at aidsinfo.nih.gov/Guidelines/.

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