There are certain vaccine considerations for people living with HIV (PLWH), which was the topic of one presentation at IDWeek 2024 in Los Angeles. Melanie Thompson, MD, past principal investigator of the AIDS Consortium of Atlanta, shared the latest immunization schedule from the Centers for Disease Control and Prevention (CDC), which includes notes specifically for PLWH:
- Herpes zoster (Shingrix): Ages 18 and older, both doses, with no CD4 criteria. People without HIV are recommended to get Shingrix to prevent shingles at age 50.
- HPV: Three doses.
- Hep A: Recommended for all PLWH, regardless of CD4 count.
- Meningococcus: Recommended for all.
- Respiratory syncytial virus (RSV): Recommended for PLWH ages 75 and older, and PLWH ages 65–74 with advanced HIV.
She had additional information about several other conditions where vaccinations are recommended for PLWH.
Hepatitis B
In a recent clinical trial, a new vaccine, Heplisav-B, was shown to be highly effective for PLWH. In the first arm of the study, two doses achieved a response in nearly all participants, and after three doses 100% had a seroprotective response. In the second arm of the trial, Heplisav-B was superior to other hep B vaccines for PLWH who had previously not responded to an older hep B vaccine, including people with low CD4 counts. The recommendation for PLWH, Dr. Thompson said, is two doses [of Heplisav], one month apart, but it should not be given to anyone who is pregnant, due to insufficient safety data.
Mpox
The CDC recommends vaccination with a two-dose Jynneos vaccine series. It’s especially important for adults at risk for serious impacts from mpox to get both doses—this includes gay, bisexual and other men who have sex with men, transgender and nonbinary people who had a new diagnosis of gonorrhea, chlamydia or syphilis in the past six months or who had sex in a commercial sex venue or in association with a public event.
Dr. Thompson said PLWH must be prioritized for mpox vaccination and treatment with a racial equity approach. Of those who died from mpox, most had HIV, mostly with very low CD4 counts, she said, noting that the vast majority of mpox deaths in the U.S. were among Black men.
Pneumococcus
Studies have shown a much higher risk of severe pneumococcal disease in people with HIV compared with people without HIV, especially those with high viral load and/or low CD4 counts, and Thompson recommended the newest pneumococcal vaccines, PVC15, PVC20 or PVC21, for PLWH.
COVID-19
COVID-19 is still with us, even though the official pandemic emergency has ended. Even a mild infection can lead to long-term health consequences, usually lumped together under the umbrella of “long COVID.” Dr. Thompson said that people with HIV and low CD4 counts do badly with COVID. “They’re at higher risk for serious disease and death for long COVID, for rapid viral evolution, and [PLWH] may be more likely to get re-infected.” Vaccination helps mitigate the risks, and people with advanced HIV, specifically a low CD4 count, should get a full series of vaccines, three mRNA shots or two doses of Novavax. If they’re completely vaxxed, they should be boosted with the updated vaccines at least once a year.
Cancer
Cancer is a leading cause of death for people with HIV, particularly non-AIDS-defining cancers like lung, anal, prostate and liver. Vaccinating against HPV and hepatitis B prevents certain cancers, and there is no age limit for cervical Pap screening for people with HIV, Dr. Thompson added.
The latest International Neoplasia Society consensus guidelines recommend screening for men who have sex with men and for transgender women with HIV at age 35 and at age 45 for all other PLWH as well as men who have sex with men and transgender women without HIV. The guidance recommends an annual digital rectal exam, regardless of whether high-resolution anoscopy is available.
Contraindicated vaccines
Dr. Thompson noted vaccines that PLWH should not get, including the live attenuated influenza vaccine and the live attenuated smallpox ACAM 2000 vaccine, which is also now used for mpox. If the CD4 count is less than 200 or HIV is uncontrolled, PLWH should not get live attenuated typhoid vaccine or MMR or varicella or yellow fever vaccines, she said.
“Remember that the response to vaccines may be low when CD4 is low, but it improves when CD4 rises,” she added.