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Methods of Infection Prevention
in Advanced HIV Care
Francesca Conradie
President of the Southern African HIV Clinicians
Society
Vaccines in HIV infected individuals
A missed opportunity
• Immunogenicity.
• Overall, vaccines tend to be less
immunogenic and antibody responses shorter
lived
• In general, the earlier in HIV infection the
better.
General considerations
• Detectable HIV RNA is associated decreased
immunogenicity
• Should delay some until VL undectable.
What vaccines should HIV + persons
receive?
Inactivated vaccines recommended for the general
adult population
• Inactivated seasonal influenza vaccine
• Tetanus toxoid and reduced diphtheria toxoid with or
without acellular pertussis vaccine (Td or TdaP)
• Human papillomavirus vaccination (up to age 26 in
HIV infected patients, if not received previously)
What vaccines should HIV + persons
receive?
Vaccines for which HIV is itself an indication
• Pneumococcal vaccination
• Hepatitis B virus vaccine (if not already
immune)
What vaccines should HIV + persons
receive?
Other vaccines are recommended for HIV infected adults only if there is a
specific indication or if there is evidence of no immunity
• Hepatitis A virus vaccine
• Meningococcal vaccination
• Haemophilus influenzae b vaccine
• Measles, mumps, rubella vaccine (if not already immune and CD4 cell
count ≥200 cells/microL)
• Varicella vaccine (if not already immune and CD4 cell count ≥200 to 350
cells/microL)
Influenza vaccine
• Does not give you flu
• Inactivated vaccine formulation is recommended
• Live, intranasal vaccines should not be used in HIV
infected patients
• Relative Risk 0.29 of acquiring flu.
•
Yamanaka H, Teruya K, Tanaka M, et al. Efficacy and immunologic responses to influenza
.
vaccine in HIV1infectedpatients. J Acquir Immune Defic Syndr 2005; 39:167
Tetanus toxoid, diphtheria toxoid, and
acellular pertussis vaccines
• Single dose (Tdap) for all who have not received Tdap
• Universal administration Td boosters every 10 years is
also recommended
• HIV infected adults have similar antibody response to
tetanus as an age matched normal population, but
diphtheria immunity is lower than expected
• Transient increase in plasma HIV1 RNA levels after
immunization with tetanus toxoid, but there were no
long term consequences of this up regulation [16].
Human papillomavirus vaccination
• All adolescents (HIV infected and uninfected) at the
ages of 11 or 12.
• Three formulations of HPV vaccine are available,
– 9 valent (Types 6, 11, 16, 18, 31, 33, 45, 52, and
58)
– Quadrivalent (Types 6, 11, 16, 18)
– Bivalent (Types 16, 18) vaccines.
Pneumococcal vaccination
Recommendations for PCV use (BHIVA)
• HIV-positive adults
• Single dose of PCV13 (polyvalent conjugate vaccine) irrespective of CD4
cell count, ART use, viral load
• At least 3 months after any use of PPSV23 (polysaccharide vaccineprime
boost)
• Revaccination with PPSV23 at least five years
• PCV13 can be given at any CD4 cell count, but it may be preferable to
defer PPSV23 administration until the CD4 cell count ≥200
• PPSV23 only for >65 years or additional co-morbidities (other than HIV)
Hepatitis B
• Surface Antibody negative- non immune
• Surface Antigen positive- infected, needs
treatment with 3TC and TDF
– 40 μg/mL (Recombivax HB) administered on a 3dose schedule or
– 20 μg/mL (Engerix-B) administered on a 4-dose
schedule at 0, 1, 2, and 6 month
Varicella
• Administer to HIV-infected persons with a CD4 count
≥200 cells/μL who do not have evidence of immunity
to varicella.
• 0.5 mL IM as 2 doses administered 3 mo apart
• Post exposure prophylaxis following exposure to
varicella zoster virus is indicated for HIV infected
individuals who do not have immunity through
natural infection or immunization.
Zoster vaccine
• Individuals with CD4 cell counts >350 cells had the highest zoster antibody
levels post vaccination.
• High rates of injection site reactions in the zoster group
• It is reasonable to vaccinate those with CD4 counts >200 cells
• Zoster vaccine is specifically not recommended for HIV infected patients
with a CD4 cell count <200
Conclusion
• Most of the vaccines are already available in
the National rollout
• Need a systematic approach to adding into
our ART program