Your activity: 6 p.v.

Immunizations in persons with HIV

Immunizations in persons with HIV
Authors:
Patricia L Hibberd, MD, PhD
Joseph Metmowlee Garland, MD, AAHIVS
Section Editor:
Rajesh T Gandhi, MD, FIDSA
Deputy Editor:
Jennifer Mitty, MD, MPH
Literature review current through: Nov 2022. | This topic last updated: Dec 22, 2022.

INTRODUCTION — Human immunodeficiency virus (HIV) infection, because of the immunocompromised state, is a risk factor for morbidity and mortality caused by a number of infections that can usually be prevented by immunization. A number of factors contribute to the patient with HIV's "net state of immunosuppression," including defects in cell-mediated immunity, B-cell dysfunction, and suboptimal humoral immune responses [1]. In the absence of effective therapy, the immunocompromise is continually progressive. On the other hand, patients who respond to antiretroviral therapy (ART) have substantial increases in their CD4 cells and improved immunity. Vaccination is most effective in patients with early HIV infection and in those on ART who are virologically suppressed and have restored CD4 function

This topic will review the approach to vaccination for vaccine-preventable diseases in persons with HIV. Treatment of these infections is discussed in the individual topic reviews. Prevention of opportunistic infections is also reviewed elsewhere. (See "Overview of prevention of opportunistic infections in patients with HIV".)

GENERAL PRINCIPLES

Inactivated versus live vaccines — Inactivated vaccines are generally safe and acceptable in individuals with HIV. Despite the greater immunogenicity in the setting of higher CD4 cell counts or virologic suppression with some vaccines, administration of inactivated vaccines does not have to be delayed if these have not yet been achieved; protective immunity with vaccination can be achieved in some patients despite immunosuppression, and the risk of infection is greatest in the setting of immunosuppression. However, if there was suboptimal antibody response to the initial vaccine, revaccination once immune reconstitution and virologic suppression has been achieved is recommended for certain vaccines.

Certain live vaccines have sufficient safety data and are thus recommended in patients with HIV who have CD4 cell percentage ≥15 percent (if <5 years old) or cell counts ≥200 cells/microL (if ≥5 years old). Live vaccines should not be given to individuals with HIV and CD4 cell parameters below these thresholds because of the absence of safety data and the concern about vaccine-associated infection.

Childhood vaccinations — All standard childhood vaccinations in the United States can be given to children with or exposed to HIV, although certain live vaccinations (such as varicella vaccine and measles, mumps, and rubella [MMR] vaccine) should be limited to individuals without severe immunosuppression (ie, CD4 cell percentage ≥15 percent). HIV infection is an indication for meningococcal conjugate vaccination in infants and children.

Adult vaccinations — Among adults, patients with HIV should receive the following categories of vaccines:

Vaccines recommended for the general adult population:

Coronavirus disease-19 (COVID-19) vaccine

Inactivated seasonal influenza vaccine

Tetanus toxoid and reduced diphtheria toxoid with or without acellular pertussis vaccine (Td or TdaP)

Human papillomavirus (HPV) vaccination (up to age 26 years in patients with HIV, if not received previously)

Vaccines for which HIV is itself an indication:

Pneumococcal vaccination

Hepatitis A virus (HAV) vaccine (if not already immune)

Hepatitis B virus (HBV) vaccine (if not already immune)

Meningococcal vaccination

Recombinant zoster vaccine

Other vaccines are recommended for adults with HIV only if there is a specific indication or if there is evidence of no immunity:

Haemophilus influenzae b vaccine (if indicated)

MMR vaccine (if not already immune and CD4 count ≥200 cells/microL)

Varicella vaccine (if not already immune and CD4 cell count ≥200 cells/microL)

Modified vaccinia Ankara (MVA; if indicated for post-exposure prophylaxis of mpox [previously referred to as monkeypox] or pre-exposure prophylaxis in some individuals at high risk of exposure)

In the United States, recommended immunizations for adults with HIV are summarized in the guidelines put forth by the Panel on Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV [2].

STANDARD IMMUNIZATIONS — Recommendations for standard immunizations vary depending upon the age of the patient. For both children and adults with HIV, the recommended formulations, dosing, or schedules for specific immunizations may differ from those for the general population in an effort to optimize the vaccine response.

Although most data on vaccinations in individuals with HIV have examined immunogenicity rather than clinical efficacy, vaccines tend to be less immunogenic and antibody responses shorter-lived in the setting of HIV infection. In general, protective antibodies are more likely elicited when vaccines are administered early in infection, prior to the decline in CD4 cell count, or after immune reconstitution and virologic suppression with antiretroviral therapy (ART).

The specific recommendations for each vaccine are discussed below (arranged alphabetically). Our approach is generally consistent with guidelines for vaccination in patients with HIV in United States (IDSA, DHHS, ACIP). Clinicians in other countries should refer to their national guidelines for recommendations regarding immunization of individuals with HIV. (See 'Society guideline links' below.)

COVID-19 vaccines — Patients with HIV ≥6months of age should receive a COVID-19 vaccine as long as there are no contraindications. The most commonly used vaccines are mRNA vaccines; however, other formulations are also available (eg, adenovirus vectors). None of the available vaccines are live or replication competent, so they are all considered safe in people living with HIV regardless of CD4 count. (See "COVID-19: Vaccines", section on 'Approach to vaccination in the United States'.)

For those who have a CD4 count ≥200 cells/microL and are virologically suppressed on ART, the approach to vaccination is the same as for immunocompetent persons. Limited data suggest that COVID vaccines induce robust antibody responses in those with HIV [3-5].

However, additional doses are indicated for those with advanced immunosuppression (CD4 <200 cells/microL, patients with a history of an AIDS-defining illness without immune reconstitution, patients with clinical manifestations of symptomatic HIV) given concerns for decreased immunogenicity [6,7]. As an example, those receiving a primary two-dose mRNA vaccine series should receive a third dose at least 28 days after the second dose to increase immune response. We use this same approach for those with a CD4 count ≥200 cells/microL if they are not receiving or are failing ART.

Detailed information on vaccine administration is discussed in a separate topic review. (See "COVID-19: Vaccines", section on 'Approach to vaccination in the United States'.)

Haemophilus influenzae vaccine — Children with HIV should receive vaccination against Haemophilus influenzae type B (Hib), as recommended for the general pediatric population without HIV [8,9] (see "Prevention of Haemophilus influenzae type b infection", section on 'Routine childhood immunization in the United States'). In addition, children with HIV ages 5 through 18 years can receive a single dose of a conjugate Hib vaccine if they have not already been vaccinated. Hib vaccine is not specifically recommended for adults with HIV unless a separate specific indication (eg, asplenia) is present [2].

As with other conjugate vaccines, antibody responses with the conjugate Hib vaccine in children with HIV have been disappointing. In one study, for example, only 37 percent of children seroconverted after administration of the Hib conjugate vaccine [10], and another report noted a lesser antibody response than controls, particularly in children with AIDS [11]. The duration of the antibody response in children is unknown. In the United States, however, Hib remains rare among children with HIV despite the suboptimal immune response, likely in part because of herd immunity conferred by routine Hib vaccination of all children [9,12].

Similarly, the incidence of Hib disease in adults with HIV is fortunately low. Adults with advanced HIV disease do have a significantly increased rate of infection with H. influenzae, but most infections involve nontypeable strains for which the vaccine is not protective.

Hepatitis A vaccine

Routine vaccination – Routine vaccination against hepatitis A virus (HAV) is recommended for all susceptible patients with HIV ≥1 year old [13,14]. Previously, HAV vaccination was recommended only for patients with HIV who had certain other indications (including chronic B or C virus infection, injection drug use, being a man who has sex with men, homelessness); however, now all individuals with HIV are recommended to receive this vaccine. The recommendation was broadened in part because of the risk for longer duration of HAV viremia in the setting of HIV, high prevalence of the prior indications among patients with HIV, and limited additional harms with a broader vaccination approach [15].

Prevaccination screening for HAV antibodies to identify susceptible individuals should be performed when the expected prevalence rates are greater than 30 percent (eg, in persons older than 40 years) [2]. We generally screen all persons with HIV because it is hard to estimate risk. However, if that is not possible, screening should be prioritized for individuals born in countries other than the United States, Canada, Western Europe, Australia, and New Zealand, where the prevalence is relatively low.

Dosing and vaccination schedules depend on the patient's age and formulation of vaccine used. If hepatitis B vaccination is also indicated, the combination hepatitis A and B vaccine (Twinrix) can be used. These issues are discussed elsewhere. (See "Hepatitis A virus infection: Treatment and prevention", section on 'Dosing and administration'.)

The anti-HAV antibody response should be assessed one month after vaccination since seroconversion for people living with HIV has been demonstrated to be lower than the extremely high rates achieved in the general population [2]. Patients without an adequate antibody response should receive a repeat vaccine series. If vaccination was administered when the CD4 count was low, repeat vaccination should be deferred until the CD4 cell count is ≥200 cells/microL. This approach differs from recommendations in the general population, in whom antibody response testing is not recommended due to an extremely high seroconversion rate. (See "Hepatitis A virus infection: Treatment and prevention", section on 'Efficacy'.)

Outbreak setting – Revaccination in the setting of an outbreak setting should be administered to individuals with a high-risk exposure, even if previously vaccinated. Case reports have demonstrated instances of persons with HIV who were previously vaccinated against HAV and subsequently acquired acute hepatitis A, as discussed below. (See "Hepatitis A virus infection: Treatment and prevention", section on 'Protection following exposure'.)

Immunogenicity and safetyHepatitis A vaccine is immunogenic in patients with HIV, although in general, antibody seroconversion rates are lower than those in patients without HIV [16-18]. This is particularly true in the setting of advanced immunosuppression [16,19,20]. HAV vaccination does not affect clinical progression or levels of HIV plasma viremia [16,19,21,22].

Immunogenicity was studied in 90 adults with HIV and 90 subjects without HIV who were given an inactivated HAV vaccine (VAQTA) at weeks 0 and 24 of the study [16]. Antibody seroconversion rates at week 28 were 94 percent among the subjects with HIV compared with 100 percent in controls without HIV. The seroconversion rate was only 87 percent in subjects with HIV and a CD4 count <300/microL compared with 100 percent in those with a CD4 count ≥300/microL.

In a study of 133 patients with HIV, seroconversion after two doses of inactivated HAV vaccine was demonstrated in 68 percent of those with CD4 counts >200 cells/microL compared with only 9 percent in those with lower CD4 cell counts [19].

In 214 patients undergoing HAV immunization, a multivariate analysis identified that the only predictor of vaccine immunogenicity was the absolute CD4 cell count; the past nadir CD4 cell count did not have any impact on antibody seroconversion [23]. Additionally, there are conflicting data on whether the presence of HIV viremia at the time of immunization affects vaccine immunogenicity [18,23].

Among those who do respond, protective antibodies persist for at least several years [18,24,25]. In a systematic review of five studies, the pooled rates of anti-HAV seropositivity among initial responders were 92 and 82 percent at two and five years, respectively [24].

Providers should be aware that patients with HIV may still be at risk for HAV infection despite a reported history of complete or partial HAV vaccination. Although no studies have evaluated the efficacy of HAV vaccination in persons with HIV, case reports have demonstrated new infection in previously vaccinated persons [26,27]. One report of an outbreak of HAV in Tennessee described 11 cases in patients with HIV [26]. Two patients had previously completed the entire series of HAV vaccine; four additional patients were incompletely vaccinated.

Hepatitis B vaccine — Routine screening for and immunization against hepatitis B virus (HBV) is recommended for all individuals with HIV to prevent primary infection [2,13,28]. For those with a history of prior vaccination, we check HBV antibodies to confirm immunity, unless a seroprotective response has been previously documented.

Persons with HIV are at increased risk of HBV infection due to shared modes of transmission. Furthermore, individuals with HIV are less likely to clear HBV DNA and are at increased risk of chronic infection [29]. Hepatitis B vaccination in persons with HIV is discussed in detail elsewhere. (See "Prevention of hepatitis B virus infection in adults with HIV" and "Hepatitis B virus immunization in infants, children, and adolescents", section on 'Routine infant immunization'.)

Herpes zoster vaccine — Persons with HIV ≥18 years of age should receive the nonlive recombinant zoster vaccine (RZV). This approach is consistent with recommendations from the United States Department of Health and Human Services [2,30]. Persons with HIV are at increased risk for herpes zoster. Although the risk of herpes zoster is reduced in those receiving ART, it remains higher than the general population [31]. (See "Epidemiology, clinical manifestations, and diagnosis of herpes zoster", section on 'HIV infection'.)

The dosing schedule for RZV is two intramuscular injections administered two to six months apart. (See "Vaccination for the prevention of shingles (herpes zoster)", section on 'Administration'.)

To maximize the response to vaccination, we typically delay RZV vaccination until patients are suppressed virologically. Some experts may also choose to delay vaccination until the count is ≥200 cells/microL [2]. However, the benefit of delaying vaccination and maximizing the immune response must be balanced against the risk of developing herpes zoster, which is greatest in the first six months after starting ART. In either case, clinicians should educate patients about early signs of herpes zoster so they can seek medical attention promptly if it occurs. (See "Epidemiology, clinical manifestations, and diagnosis of herpes zoster", section on 'Clinical manifestations' and "Treatment of herpes zoster in the immunocompetent host".)

Studies on the efficacy and safety of RZV in patients with HIV are limited. Small early phase trials suggest that RZV is safe and immunogenic in patients with HIV [30]. Data in immunocompetent patients that demonstrate greater efficacy of RZV compared with live-zoster virus vaccine (ZVL) also support the use of RZV in the HIV population. (See "Vaccination for the prevention of shingles (herpes zoster)", section on 'Efficacy'.)

Prior to the introduction of RZV, a one-dose attenuated ZVL vaccine was used for prevention of herpes zoster. Although RZV has replaced ZVL in many countries, in some countries, RZV is not available. In this setting, ZVL is reasonable for those >50 years of age with a CD4 count >200 cells/mircoL if they are receiving ART and have an undetectable viral load. In a randomized, controlled trial of 395 individuals with HIV, ZVL was found to be safe and immunogenic in in this population [32].

More detailed information on zoster vaccination is discussed elsewhere. (See "Vaccination for the prevention of shingles (herpes zoster)".)

Human papillomavirus vaccine — Vaccination against human papillomavirus (HPV) is recommended for all adolescents (with and without HIV) at 11 or 12 years of age and for individuals aged 13 through 26 who did not get any or all doses when they were younger [33]. Formulations of HPV vaccine include the 9-valent (Types 6, 11, 16, 18, 31, 33, 45, 52, and 58), the quadrivalent (Types 6, 11, 16, 18) and bivalent (Types 16, 18) vaccines. In the United States, only the 9-valent vaccine is available. A detailed discussion regarding HPV vaccination is found elsewhere. (See "Human papillomavirus vaccination", section on 'Administration' and "Human papillomavirus vaccination", section on 'Patients with HIV or immunocompromising conditions'.)

HPV testing prior to vaccination is not necessary. A history of genital warts, abnormal cytology, or positive HPV DNA test result is not evidence of prior infection with any or all of the vaccine HPV types and thus should not preclude vaccination if indicated by age [13].

HPV vaccination may also be of benefit in select older individuals who had not been previously vaccinated. Although the maximum recommended age for vaccination is 26, this age is used since it was the upper age range of the patients included in vaccine trials. In the United States, FDA approval has been given for HPV vaccines through age 45 years. However, for persons with HIV, we do not routinely administer HPV vaccination to those 27 to 45 years of age who were not adequately vaccinated, since many patients with HIV have already had prior exposure to pathogenic strains of HPV by the age of 27 years, and HPV vaccination may have little benefit. Instead, we use shared decision-making to determine the need for vaccination, taking into account the likelihood the individual will respond to vaccination and elicit some benefit (eg, someone with minimal HPV exposure) as well as the risks of vaccination.

The safety and immunogenicity of HPV vaccines in persons with HIV is discussed in a separate topic review. (See "Human papillomavirus vaccination", section on 'Patients with HIV or immunocompromising conditions'.)

Influenza vaccine — Annual administration of the seasonal influenza vaccine is recommended for all patients with HIV aged six months and older [2,8,9,34].

Live, intranasal vaccines should not be used in patients with HIV. The specific schedule and inactivated vaccine components are the same as those for the general population and are discussed elsewhere. As with the general adult population, if a trivalent formulation of the influenza vaccine is available immediately and the quadrivalent vaccine is not available, it is preferable to administer the trivalent vaccine rather than delay vaccination. (See "Seasonal influenza vaccination in adults".)

Efficacy, immunogenicity, and safety – Several studies have demonstrated the efficacy and safety of influenza vaccine [35-44]. In a systematic review of studies evaluating the efficacy of influenza vaccination, the rate of influenza-like illness (in 13 studies) and laboratory-confirmed influenza (in four studies) was lower among vaccinated compared with unvaccinated patients with HIV; the rate of influenza-like illness was comparable to that in vaccinated patients without immune compromise [45]. The following studies were included in the analysis:

In a placebo-controlled trial of 102 patients with HIV, influenza vaccination resulted in significant reductions in respiratory symptoms (29 versus 49 percent) and laboratory-confirmed infection (0 versus 21 percent) [40].

In a prospective study of 328 patients who were advised to have influenza vaccine, vaccination was associated with a lower risk of subsequent laboratory-confirmed influenza among the 262 who agreed to immunization compared with the 66 who did not (relative risk 0.29) [35].

In some studies, antibody responses following standard-dose influenza vaccines have been lower in individuals with HIV than in immunocompetent hosts [45,46]. An important question is whether using a high-dose influenza vaccine will improve immunogenicity and efficacy in individuals with HIV. The question of immunogenicity was addressed in a randomized trial that compared a standard dose (15 mcg of antigen per strain) with a high dose (60 mcg per strain) of the inactivated trivalent influenza vaccine in individuals with HIV [47]. Seroprotection rates following vaccination were significantly higher in the high-dose group for the H1N1 influenza A (96 versus 87 percent) and influenza B (91 versus 80 percent) components but not for H3N2 influenza A (96 versus 92 percent, a nonsignificant difference). Further studies are warranted to evaluate the efficacy of the high-dose influenza vaccine in adults with HIV.

Intradermal delivery of influenza vaccine, another strategy to increase immunogenicity, did not improve seroconversion rates compared with intramuscular delivery in a trial of men with HIV in Thailand [48]. (See "Seasonal influenza vaccination in adults", section on 'Intradermal vaccine delivery' and "Seasonal influenza vaccination in adults".)

There are conflicting results as to whether influenza vaccination leads to a transient upregulation of HIV replication [36-40,45]. However, there are no studies to suggest any negative effect on HIV disease progression. The safety of the influenza vaccine in general is discussed separately. (See "Seasonal influenza vaccination in adults".)

Risk factors for poor response – Since the antibody response to vaccination is critically dependent upon CD4 cell function, a poor vaccine response can be expected in patients with HIV, particularly those with advanced disease. Loss of CD4 cells is associated with weak influenza-specific antibody responses, as measured by titers and influenza-specific antibody secreting cells [35,49,50]. In fact, use of the vaccine has been questioned for patients with more advanced disease on a cost-benefit basis [51].

As in other vaccine studies in patients with HIV (eg, hepatitis B), the presence of circulating HIV RNA has also been demonstrated to be an important predictor of nonresponse to influenza vaccination [52]. This suggests that the immunogenicity of the vaccine may be improved with viral suppression on ART.

Measles, mumps, and rubella vaccine — Vaccination for measles, mumps, and rubella (MMR) is a live vaccine that is recommended for children with HIV who are without evidence of severe immunosuppression (ie, CD4 cell percentage ≥15 percent) [8,9,53]. A detailed discussion of MMR vaccination in children with HIV is discussed elsewhere. (See "Measles, mumps, and rubella immunization in infants, children, and adolescents", section on 'Other special circumstances'.)

For older children and adults with newly diagnosed HIV who are without acceptable evidence of MMR immunity, two doses of MMR vaccine, given at least 28 days apart, are recommended unless they have evidence of severe immunosuppression (ie, CD4 percentage <15 percent or, if older than five years, a CD4 count <200 cells/microL) [53]. Acceptable evidence of immunity includes birth before 1957, history of prior vaccination, or laboratory evidence of immunity or disease.

Administration of MMR vaccine is not recommended in patients with HIV and severe immunosuppression [8,53]. Additionally, administration of the measles, mumps, rubella, and varicella combination vaccine is not recommended in patients with HIV as it has not been studied in this population.

Measles can be a life-threatening infection in immunocompromised patients. In the pre-ART era, the case-fatality rate for patients with HIV was reported to be as high as 40 percent [54]. Since the number of measles cases has been increasing in the United States, as well as in other countries, prevention of measles in HIV infection is of major importance. (See "Measles: Epidemiology and transmission".)

The MMR vaccine is safe in patients with HIV and without severe immunosuppression [55,56]. However, the antibody response to MMR vaccine in children and adults with HIV is low, even among those receiving ART [55,57,58], although in one study of children on ART, a second MMR dose improved protective antibody development [59].

The majority of adults with HIV are seropositive to measles, even if the CD4 cell count is <200 cells/microL [57], suggesting that protective antibodies elicited by MMR vaccination prior to HIV infection are not substantially effected by HIV-associated immune decline.

Meningococcal vaccine

Indications – Vaccination with meningococcal conjugate vaccine (MenACWY-CRM [Menveo] and MenACWY-TT [MenQuadFi]), which include serogroups A, C, W, and Y, is recommended for all individuals with HIV two months of age or older [8,60]. In the United States, MenACWY-D (Menactra) was discontinued in June 2022.

The main rationale for meningococcal vaccination is the risk of invasive meningococcal disease in individuals with HIV. Growing evidence has suggested that individuals with HIV have a higher risk for invasive meningococcal disease, with an estimated relative risk of 11 to 24 times that of the general population [60-65]. As an example, in a retrospective database study, the estimated annual incidence of invasive meningococcal infection in New York City between 2000 and 2011 was 0.39 cases per 100,000 persons overall and 3.4 per 100,000 persons among those with HIV [61]. The risk was especially high among those with CD4 counts <200 cells/microL. (See "Epidemiology of Neisseria meningitidis infection", section on 'HIV infection'.)

In addition, serogroup B meningococcal vaccination may also be indicated (eg, in the United States, it is recommended for those with persistent complement component deficiencies or anatomic or functional asplenia, for microbiologists routinely exposed to isolates of Neisseria meningitidis, and in the setting of outbreaks of serogroup B meningococcal disease). (See "Meningococcal vaccination in children and adults", section on 'Serogroup B vaccines' and "Meningococcal vaccination in children and adults", section on 'Immunization of persons at increased risk'.)

Administration – MenACWY-CRM, MenACWY-D, or MenACWY-TT can be used in individuals with HIV, and the choice between them depends on availability and clinician familiarity. If MenACWY-D is used, it should be administered at least four weeks after pneumococcal conjugate vaccine and in children should be administered before or at the same time as the diphtheria, tetanus toxoids, and pertussis (DTaP) vaccine.

The recommended schedule for meningococcal conjugate vaccination for individuals with HIV varies by age (algorithm 1 and table 1A-B) [60]. The schedule is based on immunogenicity studies that demonstrate improved antibody responses with two vaccine doses but waning immunity over time. Dosing is described in detail in a separate topic review. (See "Meningococcal vaccination in children and adults", section on 'Immunization of persons at increased risk'.)

For those who have indications for serogroup B vaccination, either serogroup B vaccine (Truemba or Bexsero) can be used, but the same vaccine should be used throughout the series. (See "Epidemiology of Neisseria meningitidis infection", section on 'Outside the United States' and "Epidemiology of Neisseria meningitidis infection", section on 'Men who have sex with men'.)

Immunogenicity and safety – The immunogenicity of meningococcal conjugate vaccine has not been specifically studied in adults with HIV older than 24 years and is extrapolated for this age group from studies among younger patients. In children without low CD4 cell counts, a single dose of meningococcal conjugate vaccine elicited antibody responses that were generally lower than in patients without HIV and varied by serogroup but exceeded protective levels in the majority of patients [66,67]. In a separate randomized trial of adolescents and young adults with HIV aged 11 to 24 years, protective levels were also achieved in the majority [68]. Two conjugate vaccine doses resulted in higher rates of protective immune responses than a single dose, although the differences in rates decreased by 72 weeks postvaccination; immune responses were poor among the small group of patients with CD4 cell percentage <15 percent despite two doses. Thus, for individuals with HIV, two doses are recommended for the primary vaccine series, with subsequent interval boosting doses because of waning immunity, as described above.

Only one serious adverse event in these studies was thought to be potentially related to vaccine receipt (migraine and ocular pain) [68].

Pneumococcal vaccine — Vaccination against Streptococcus pneumoniae is recommended for all patients with HIV. The dosing schedule depends on the patient's immunization history and the availability of vaccines [2,8,69-71]. Specific recommendations for pneumococcal vaccination in adults and children with HIV are found elsewhere. (See "Pneumococcal immunization in adults with HIV" and "Pneumococcal vaccination in children", section on 'Immunization of high-risk children and adolescents'.)

Poliovirus vaccine — Infants and children with HIV should receive inactivated polio vaccine as recommended for the general population. The small number of adults with HIV at risk of exposure to polio (by travel or work) should receive a primary series inactivated polio vaccine (IPV) if there is no documentation of vaccination status [72]. A single lifetime booster with IPV is recommended for adults at continued risk of exposure to polio, although the duration of protection is unknown [72]. (See "Poliovirus vaccination".)

Rotavirus vaccine — Rotavirus vaccination is not contraindicated in infants with or exposed to HIV and is generally supported by expert groups [8,9]. Dosing and schedule recommendations are the same as for infants without HIV. (See "Rotavirus vaccines for infants", section on 'Precautions' and "Rotavirus vaccines for infants", section on 'Schedule'.)

Tetanus toxoid, diphtheria toxoid, and acellular pertussis vaccines — Patients with HIV should receive tetanus, diphtheria, and pertussis immunizations based upon routine recommendations for adults and children [2]. (See "Tetanus-diphtheria toxoid vaccination in adults" and "Diphtheria, tetanus, and pertussis immunization in children 7 through 18 years of age", section on 'Schedule' and "Diphtheria, tetanus, and pertussis immunization in children 6 weeks through 6 years of age", section on 'Indications'.)

Apart from the primary vaccine series, these recommendations include a single dose of a vaccine containing tetanus toxoid, reduced diphtheria toxoid, and reduced acellular pertussis (Tdap) for all individuals aged 11 years and older who have not received Tdap previously to address waning immunity against pertussis [73]. Universal administration of either the tetanus toxoid and reduced diphtheria toxoid (Td) or Tdap boosters every 10 years is also recommended because of waning immunity against tetanus and diphtheria over time [13]. If possible, we prefer Tdap over Td for all booster doses, given the additional coverage.

Additionally, all pregnant women should receive vaccination against pertussis with Tdap during each pregnancy [73]. (See "Immunizations during pregnancy", section on 'Tetanus, diphtheria, and pertussis vaccination'.)

Several studies have evaluated the immunogenicity of these vaccines in patients with HIV, but the results are difficult to compare because of the various vaccine formulations and schedules used. In general, immunogenicity appears somewhat lower and shorter-lived than that observed among the general population [8,24]. Adults with HIV have similar antibody response to tetanus as an age-matched normal population, but diphtheria immunity is lower than expected [74]. Among those with advanced HIV, the response to immunization with both tetanus and diphtheria is lower compared with the general population, since the immune responses to tetanus and diphtheria are T cell-dependent [49,75].

These vaccinations are safe among those with HIV [8]. One study noted a transient increase in plasma HIV-1 RNA levels after immunization with tetanus toxoid, but there were no long-term consequences of this upregulation [76].

Varicella vaccine

Indications and administrationVaricella vaccine is a live virus vaccine recommended for children with HIV who do not have evidence of severe immunosuppression (ie, CD4 cell percentage ≥15 percent) [2,8,9]. In addition, we recommend administration of varicella vaccine to adults and adolescents with HIV and CD4 cell counts ≥200 cells/microL if they were born after 1979 and do not have evidence of immunity (antivaricella immunoglobulin [Ig]G antibody levels) or a history of two prior doses of the varicella vaccine administered when their CD4 counts were ≥200 cells/microL. For those with CD4 counts less than 200 cells/microL, we recommend deferring the varicella vaccine until the counts are above that threshold. This is consistent with ACIP and IDSA recommendations to consider varicella vaccination in adults and adolescents with HIV and without immunity to varicella-zoster virus who have CD4 cell counts ≥200 cells/microL [2,8,9,13].

The varicella vaccine should not be administered to patients with HIV and severe immunosuppression (ie, CD4 cell percentage <15 percent or, if older than five years, a CD4 count <200 cells/microL) [2,8,9,13]. Additionally, administration of the measles, mumps, rubella, and varicella combination vaccine is not recommended in patients with HIV as it has not been studied in this population.

Varicella vaccine is administered in two doses given three months apart [2,13]. Eligible children should receive the vaccination as soon as possible after the first birthday. (See "Vaccination for the prevention of chickenpox (primary varicella infection)".)

Post-exposure prophylaxis following exposure to varicella-zoster virus is indicated for individuals with HIV who do not have immunity through natural infection or immunization. This is discussed in detail elsewhere. (See "Post-exposure prophylaxis against varicella-zoster virus infection".)

Immunogenicity and safety – Primary varicella can cause severe illness in children and adults with HIV [2]. Varicella vaccine has been demonstrated to be safe [77], effective [78], and immunogenic in asymptomatic children with HIV and CD4 percentages of 25 percent or more [79-82]. One study evaluated the safety and efficacy of varicella vaccine in children with a history of severe immunosuppression who had achieved immune reconstitution (n = 17) and in those with moderate symptoms and CD4 percentages ≥15 percent (n = 37) [83]. Regardless of immunologic category, 79 percent of vaccine recipients with HIV developed varicella-zoster virus-specific antibody and/or cell-mediated immunity 60 days after the immunization series. A multivariate analysis indicated that detectable HIV viremia at baseline correlated with a lower likelihood of immunization response.

Varicella vaccine has not been studied systematically in adults, but most experts feel that adult patients with clinically stable HIV and a CD4 count ≥200 cells/microL would have comparable immunity to the children with HIV described above.

In studies in children, varicella vaccination did not affect the CD4 cell percentage or plasma viral level [80,83].

Other risks associated with varicella vaccination are discussed elsewhere. If vaccination results in disease because of vaccine virus, therapy with acyclovir is recommended [2]. (See "Vaccination for the prevention of chickenpox (primary varicella infection)", section on 'Adverse events'.)

ADDITIONAL CONSIDERATIONS

BCG vaccine — Bacillus Calmette Guerin (BCG) vaccines are administered to newborn infants in developing countries to reduce the risk of developing tuberculosis. Advisory groups have recommended against use of the BCG vaccine in all persons with HIV, even if the risk of acquiring tuberculosis is high since the efficacy of the vaccine in patients with HIV is unknown and disseminated BCG has been reported after vaccination [84,85], with complications occurring up to many years after vaccination [86,87].

Orthopoxvirus vaccines — During the outbreak of mpox (previously referred to as monkeypox) that started in May 2022, orthopoxvirus virus vaccination has been used as post-exposure prophylaxis to reduce the risk of developing infection after a known or presumed exposure to mpox. It is also offered as pre-exposure prophylaxis to selected persons at high risk of exposure to mpox. (See "Treatment and prevention of mpox (monkeypox)", section on 'Post-exposure prophylaxis' and "Treatment and prevention of mpox (monkeypox)", section on 'Pre-exposure prophylaxis with orthopoxvirus vaccines'.)

There are two available vaccines that can reduce the risk of developing mpox, the modified vaccinia Ankara (MVA) vaccine (JYNNEOS in the United States, IMVANEX in the European Union, and IMVAMUNE in Canada) and ACAM2000 vaccine. However, only the MVA vaccine should be used in persons with HIV.

The MVA vaccine is made from a highly attenuated, nonreplicating vaccinia virus and has an excellent safety profile, even in immunocompromised people and those with skin disorders. Studies have found the MVA vaccine to be immunogenic and safe in persons with HIV [88,89].

The MVA vaccine is administered as two doses four weeks apart. Detailed information about this vaccine, including dosing and administration, is presented in a separate topic review. (See "Vaccines to prevent smallpox, mpox (monkeypox), and other orthopoxviruses", section on 'Modified vaccinia Ankara (non-replicating) vaccine'.)

ACAM2000 is a replication-competent smallpox vaccine that is associated with more adverse events than the MVA vaccine. For persons with HIV, ACAM2000 should be reserved for prevention of smallpox in an outbreak situation.

Additional information on these vaccines can be found on the CDC website.

Yellow fever vaccine — Yellow fever vaccine is a live vaccine that can be administered, if indicated, to patients with HIV and CD4 cell counts ≥200 cells/microL [90]. However, it is contraindicated in patients with lower CD4 cell counts due to concerns regarding risk of live virus vaccine in patients with advanced immunosuppression.

In a systematic review of observational studies that included approximately 450 patients with HIV (most of whom had CD4 cell counts ≥200 cells/microL), there were no serious adverse events reported [91].

Although yellow fever vaccine appears to be safe among patients with HIV and without severe immunosuppression, it is less immunogenic than among individuals without HIV [92-94]. In a retrospective study of 102 patients from the Swiss HIV Cohort who were identified who had received yellow fever vaccine, protective antibodies were detected less frequently and at lower neutralization titers compared with a separate cohort of patients without HIV [93].

In one prospective study of 240 patients with HIV who received yellow fever vaccine after their HIV diagnosis, failure to achieve a significant level of neutralizing antibodies was associated with detectable HIV RNA at the time of immunization [95]. There are conflicting data as to whether the level of immunosuppression is associated with vaccine immunogenicity [93,95].

Indications and general risks of the yellow fever vaccine are discussed in detail elsewhere. (See "Yellow fever: Treatment and prevention", section on 'Prevention'.)

PASSIVE IMMUNIZATION — Since patients with HIV and low CD4 cell counts may not be able to make effective new antibodies despite vaccination, the use of hyperimmune globulin preparations can be considered in some immunocompromised patients following high-risk exposures, such as to varicella, hepatitis A, or measles. (See "Post-exposure prophylaxis against varicella-zoster virus infection", section on 'Passive immunoprophylaxis' and "Hepatitis A virus infection: Treatment and prevention", section on 'Protection following exposure' and "Measles, mumps, and rubella immunization in adults", section on 'Postexposure prophylaxis'.)

SPECIAL POPULATIONS

Immunizations in travelers — Immunizations in travelers are discussed separately. The use of the different vaccines must be considered in relation to the issues described above. (See "Immunizations for travel".)

Immunizations in pregnant women — Pregnant women with HIV should receive the routine vaccinations recommended during pregnancy in general, namely the inactivated seasonal influenza vaccine and the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine. Receipt of other vaccines that may be indicated because of HIV infection or a different comorbidity depend on the recommendations for administration during pregnancy. These are discussed in detail elsewhere. (See "Immunizations during pregnancy".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Immunizations in patients with HIV" and "Society guideline links: Immunizations in adults".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Vaccines for adults with HIV (The Basics)" and "Patient education: What you should know about vaccines (The Basics)" and "Patient education: Vaccines for adults (The Basics)")

Beyond the Basics topic (see "Patient education: Vaccines for adults (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

General principles

Defects in immune response – Patients with HIV have defects in cell-mediated immunity, B-cell dysfunction, and suboptimal humoral immune responses. Thus, antibody responses to vaccines are often less robust among persons with HIV compared to those without HIV. Specific formulations, dosing, and schedules of vaccines as well as postvaccine evaluation of antibody responses can be utilized to optimize their impact. (See 'General principles' above.)

Inactivated versus live vaccines – In general, live vaccines should be avoided in individuals with HIV who have CD4 cell percentages <15 percent (if <5 years of age) or CD4 counts <200 cells/microL (if >5 five years of age). However, several live vaccines are acceptable for nonimmune patients with CD4 cell parameters above these thresholds. These include the measles, mumps, and rubella (MMR) vaccine, varicella vaccine, and yellow fever vaccine. By contrast, the live influenza vaccine and Bacillus Calmette Guerin (BCG) vaccine should be avoided, regardless of the CD4 count. (See 'Inactivated versus live vaccines' above.)

Routine vaccinations – All standard childhood immunizations in the United States can be given to children with or exposed to HIV, although live vaccines should be deferred in individuals who are severely immunocompromised. (See 'Childhood vaccinations' above.)

Adults with HIV should receive seasonal influenza vaccine and tetanus, diphtheria, and pertussis immunizations according to routine recommendations for the general population (figure 1). In addition, there are certain vaccines for which HIV is itself an indication. These include pneumococcal vaccination, hepatitis A virus (HAV) vaccine, hepatitis B virus (HBV) vaccine, meningococcal vaccination, and the recombinant zoster vaccine. (See 'Adult vaccinations' above.)

Vaccine-specific considerations for persons living with HIV

COVID-19 vaccines – Persons with HIV should receive the COVID-19 vaccine. Although specific data on the efficacy and safety of COVID-19 vaccines in individuals with HIV are limited, the benefits likely outweigh any potential risks in the setting of HIV.

Individuals with advanced immunosuppression (CD4 <200 cells/microL, patients with a history of an AIDS-defining illness without immune reconstitution, and patients with clinical manifestations of symptomatic HIV) who received a two-dose mRNA vaccine series should receive a third dose at least 28 days after the second dose to increase immune response. (See 'COVID-19 vaccines' above.)

Hepatitis A vaccination – Persons with HIV who are not immune to HAV should receive the HAV vaccine series. Adequate immunologic response should be checked with serum hepatitis A IgG antibody testing. (See 'Hepatitis A vaccine' above.)

Hepatitis B vaccination – Persons with HIV who are not immune to HBV should receive the HBV vaccine series. Strategies to improve antibody response to the HBV vaccine include evaluating choice of vaccine, using a double dose of vaccine, checking for vaccine response, and revaccinating nonresponders. (See 'Hepatitis B vaccine' above.)

Herpes zoster vaccinationRecombinant zoster vaccine (RZV) is administered as two doses, at least eight weeks apart. Persons with HIV are at increased risk for herpes zoster. Although the risk of herpes zoster is reduced in those receiving antiretroviral therapy (ART), it remains higher than the general population. (See 'Herpes zoster vaccine' above.)

Human papilloma virus vaccination – Human papillomavirus (HPV) vaccine should be administered to individuals with HIV through age 26 years if they did not receive any or all doses when they were younger. HPV DNA screening is not recommended prior to immunization. (See 'Human papillomavirus vaccine' above.)

Meningococcal vaccination – All individuals with HIV older than two months should receive the meningococcal conjugate vaccination (Menactra, Menveo, or MenQuadFi). Meningococcal vaccination is administered as a primary series followed by interval boosting doses; the precise schedule depends on the age of the patient (algorithm 1). Serogroup B meningococcal vaccination may also be indicated depending on patient risk factors. (See 'Meningococcal vaccine' above.)

Pneumococcal vaccination – Vaccination against Streptococcus pneumoniae is recommended for all patients with HIV. The dosing schedule depends on the patient's immunization history and the availability of vaccines. The approach to vaccination is discussed in detail in separate topic reviews. (See "Pneumococcal immunization in adults with HIV" and "Pneumococcal vaccination in children", section on 'Immunization of high-risk children and adolescents'.)

Orthopoxvirus vaccines – The modified vaccinia Ankara (MVA) vaccine is approved for prevention of mpox (previously referred to as monkeypox) and smallpox. This vaccine is considered safe for use in persons living with HIV as it is not replication competent. By contrast, the ACAM2000 smallpox vaccine should generally be avoided in persons with HIV, except in the setting of a smallpox outbreak. (See 'Orthopoxvirus vaccines' above.)

ACKNOWLEDGMENT — We are saddened by the death of John G Bartlett, MD, who passed away in January 2021. UpToDate gratefully acknowledges Dr. Bartlett's role as section editor on this topic, his tenure as the founding Editor-in-Chief for UpToDate in Infectious Diseases, and his dedicated and longstanding involvement with the UpToDate program.

  1. Titanji K, De Milito A, Cagigi A, et al. Loss of memory B cells impairs maintenance of long-term serologic memory during HIV-1 infection. Blood 2006; 108:1580.
  2. Panel on Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association, and Infectious Diseases Society of America. Available at https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-opportunistic-infection (Accessed on December 14, 2022).
  3. Woldemeskel BA, Karaba AH, Garliss CC, et al. The BNT162b2 mRNA Vaccine Elicits Robust Humoral and Cellular Immune Responses in People Living With Human Immunodeficiency Virus (HIV). Clin Infect Dis 2022; 74:1268.
  4. Ruddy JA, Boyarsky BJ, Werbel WA, et al. Safety and antibody response to the first dose of severe acute respiratory syndrome coronavirus 2 messenger RNA vaccine in persons with HIV. AIDS 2021; 35:1872.
  5. Ruddy JA, Boyarsky BJ, Bailey JR, et al. Safety and antibody response to two-dose SARS-CoV-2 messenger RNA vaccination in persons with HIV. AIDS 2021; 35:2399.
  6. Benet S, Blanch-Lombarte O, Ainsua-Enrich E, et al. Limited Humoral and Specific T-Cell Responses After SARS-CoV-2 Vaccination in PWH With Poor Immune Reconstitution. J Infect Dis 2022; 226:1913.
  7. Chammartin F, Kusejko K, Pasin C, et al. Determinants of antibody response to severe acute respiratory syndrome coronavirus 2 mRNA vaccines in people with HIV. AIDS 2022; 36:1465.
  8. Rubin LG, Levin MJ, Ljungman P, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis 2014; 58:e44.
  9. Department of Health and Human Services. Panel on Opportunistic Infections in HIV-Exposed and HIV-Infected Children. Guidelines for the prevention and treatment of opportunistic infections in HIV-exposed and HIV-infected children. aidsinfo.nih.gov/contentfiles/lvguidelines/oi_guidelines_pediatrics.pdf (Accessed on February 08, 2019).
  10. Peters VB, Sood SK. Immunity to Haemophilus influenzae type b polysaccharide capsule in children with human immunodeficiency virus infection immunized with a single dose of Haemophilus vaccine. J Pediatr 1994; 125:74.
  11. Chadwick EG, Chang G, Decker MD, et al. Serologic response to standard inactivated influenza vaccine in human immunodeficiency virus-infected children. Pediatr Infect Dis J 1994; 13:206.
  12. Rongkavilit C, Rodriguez ZM, Gómez-Marín O, et al. Gram-negative bacillary bacteremia in human immunodeficiency virus type 1-infected children. Pediatr Infect Dis J 2000; 19:122.
  13. Freedman M, Kroger A, Hunter P, et al. Recommended Adult Immunization Schedule, United States, 2020. Ann Intern Med 2020; 172:337.
  14. Doshani M, Weng M, Moore KL, et al. Recommendations of the Advisory Committee on Immunization Practices for Use of Hepatitis A Vaccine for Persons Experiencing Homelessness. MMWR Morb Mortal Wkly Rep 2019; 68:153.
  15. ACIP Summary Report, June 26-27, 2019. https://www.cdc.gov/vaccines/acip/meetings/downloads/min-archive/min-2019-06-508.pdf (Accessed on March 05, 2020).
  16. Wallace MR, Brandt CJ, Earhart KC, et al. Safety and immunogenicity of an inactivated hepatitis A vaccine among HIV-infected subjects. Clin Infect Dis 2004; 39:1207.
  17. Shire NJ, Welge JA, Sherman KE. Efficacy of inactivated hepatitis A vaccine in HIV-infected patients: a hierarchical bayesian meta-analysis. Vaccine 2006; 24:272.
  18. Crum-Cianflone NF, Wilkins K, Lee AW, et al. Long-term durability of immune responses after hepatitis A vaccination among HIV-infected adults. J Infect Dis 2011; 203:1815.
  19. Kemper CA, Haubrich R, Frank I, et al. Safety and immunogenicity of hepatitis A vaccine in human immunodeficiency virus-infected patients: a double-blind, randomized, placebo-controlled trial. J Infect Dis 2003; 187:1327.
  20. Neilsen GA, Bodsworth NJ, Watts N. Response to hepatitis A vaccination in human immunodeficiency virus-infected and -uninfected homosexual men. J Infect Dis 1997; 176:1064.
  21. Bodsworth NJ, Neilsen GA, Donovan B. The effect of immunization with inactivated hepatitis A vaccine on the clinical course of HIV-1 infection: 1-year follow-up. AIDS 1997; 11:747.
  22. Santagostino E, Gringeri A, Rocino A, et al. Patterns of immunogenicity of an inactivated hepatitis A vaccine in anti-HIV positive and negative hemophilic patients. Thromb Haemost 1994; 72:508.
  23. Rimland D, Guest JL. Response to hepatitis A vaccine in HIV patients in the HAART era. AIDS 2005; 19:1702.
  24. Kernéis S, Launay O, Turbelin C, et al. Long-term immune responses to vaccination in HIV-infected patients: a systematic review and meta-analysis. Clin Infect Dis 2014; 58:1130.
  25. Cheng A, Chang SY, Sun HY, et al. Long-term Durability of Responses to 2 or 3 Doses of Hepatitis A Vaccination in Human Immunodeficiency Virus-Positive Adults on Antiretroviral Therapy. J Infect Dis 2017; 215:606.
  26. Brennan J, Moore K, Sizemore L, et al. Notes from the Field: Acute Hepatitis A Virus Infection Among Previously Vaccinated Persons with HIV Infection - Tennessee, 2018. MMWR Morb Mortal Wkly Rep 2019; 68:328.
  27. McLaughlin SE, Simmons JD, Armstrong H, et al. Acute Hepatitis A Viral Infection in People With HIV With Previously Documented Hepatitis A Immunity or Appropriate Vaccination: A Case Series. Open Forum Infect Dis 2021; 8:ofab347.
  28. Brook G. Prevention of viral hepatitis in HIV co-infection. J Hepatol 2006; 44:S104.
  29. Hadler SC, Judson FN, O'Malley PM, et al. Outcome of hepatitis B virus infection in homosexual men and its relation to prior human immunodeficiency virus infection. J Infect Dis 1991; 163:454.
  30. Berkowitz EM, Moyle G, Stellbrink HJ, et al. Safety and immunogenicity of an adjuvanted herpes zoster subunit candidate vaccine in HIV-infected adults: a phase 1/2a randomized, placebo-controlled study. J Infect Dis 2015; 211:1279.
  31. Grabar S, Tattevin P, Selinger-Leneman H, et al. Incidence of herpes zoster in HIV-infected adults in the combined antiretroviral therapy era: results from the FHDH-ANRS CO4 cohort. Clin Infect Dis 2015; 60:1269.
  32. Benson CA, Andersen JW, Macatangay BJC, et al. Safety and Immunogenicity of Zoster Vaccine Live in Human Immunodeficiency Virus-Infected Adults With CD4+ Cell Counts >200 Cells/mL Virologically Suppressed on Antiretroviral Therapy. Clin Infect Dis 2018; 67:1712.
  33. Meites E, Szilagyi PG, Chesson HW, et al. Human Papillomavirus Vaccination for Adults: Updated Recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep 2019; 68:698.
  34. Centers for Disease Control and Prevention (CDC). Prevention and control of seasonal influenza with vaccines. Recommendations of the Advisory Committee on Immunization Practices--United States, 2013-2014. MMWR Recomm Rep 2013; 62:1.
  35. Yamanaka H, Teruya K, Tanaka M, et al. Efficacy and immunologic responses to influenza vaccine in HIV-1-infected patients. J Acquir Immune Defic Syndr 2005; 39:167.
  36. Staprans SI, Hamilton BL, Follansbee SE, et al. Activation of virus replication after vaccination of HIV-1-infected individuals. J Exp Med 1995; 182:1727.
  37. Røsok B, Voltersvik P, Bjerknes R, et al. Dynamics of HIV-1 replication following influenza vaccination of HIV+ individuals. Clin Exp Immunol 1996; 104:203.
  38. Ramilo O, Hicks PJ, Borvak J, et al. T cell activation and human immunodeficiency virus replication after influenza immunization of infected children. Pediatr Infect Dis J 1996; 15:197.
  39. Glesby MJ, Hoover DR, Farzadegan H, et al. The effect of influenza vaccination on human immunodeficiency virus type 1 load: a randomized, double-blind, placebo-controlled study. J Infect Dis 1996; 174:1332.
  40. Tasker SA, Treanor JJ, Paxton WB, Wallace MR. Efficacy of influenza vaccination in HIV-infected persons. A randomized, double-blind, placebo-controlled trial. Ann Intern Med 1999; 131:430.
  41. Madhi SA, Maskew M, Koen A, et al. Trivalent inactivated influenza vaccine in African adults infected with human immunodeficient virus: double blind, randomized clinical trial of efficacy, immunogenicity, and safety. Clin Infect Dis 2011; 52:128.
  42. Bickel M, Wieters I, Khaykin P, et al. Low rate of seroconversion after vaccination with a split virion, adjuvanted pandemic H1N1 influenza vaccine in HIV-1-infected patients. AIDS 2010; 24:F31.
  43. Tebas P, Frank I, Lewis M, et al. Poor immunogenicity of the H1N1 2009 vaccine in well controlled HIV-infected individuals. AIDS 2010; 24:2187.
  44. Kajaste-Rudnitski A, Galli L, Nozza S, et al. Induction of protective antibody response by MF59-adjuvanted 2009 pandemic A/H1N1v influenza vaccine in HIV-1-infected individuals. AIDS 2011; 25:177.
  45. Beck CR, McKenzie BC, Hashim AB, et al. Influenza vaccination for immunocompromised patients: systematic review and meta-analysis by etiology. J Infect Dis 2012; 206:1250.
  46. George VK, Pallikkuth S, Parmigiani A, et al. HIV infection Worsens Age-Associated Defects in Antibody Responses to Influenza Vaccine. J Infect Dis 2015; 211:1959.
  47. McKittrick N, Frank I, Jacobson JM, et al. Improved immunogenicity with high-dose seasonal influenza vaccine in HIV-infected persons: a single-center, parallel, randomized trial. Ann Intern Med 2013; 158:19.
  48. Garg S, Thongcharoen P, Praphasiri P, et al. Randomized Controlled Trial to Compare Immunogenicity of Standard-Dose Intramuscular Versus Intradermal Trivalent Inactivated Influenza Vaccine in HIV-Infected Men Who Have Sex With Men in Bangkok, Thailand. Clin Infect Dis 2016; 62:383.
  49. Kroon FP, van Dissel JT, de Jong JC, van Furth R. Antibody response to influenza, tetanus and pneumococcal vaccines in HIV-seropositive individuals in relation to the number of CD4+ lymphocytes. AIDS 1994; 8:469.
  50. Malaspina A, Moir S, Orsega SM, et al. Compromised B cell responses to influenza vaccination in HIV-infected individuals. J Infect Dis 2005; 191:1442.
  51. Rose DN, Schechter CB, Sacks HS. Influenza and pneumococcal vaccination of HIV-infected patients: a policy analysis. Am J Med 1993; 94:160.
  52. Evison J, Farese S, Seitz M, et al. Randomized, double-blind comparative trial of subunit and virosomal influenza vaccines for immunocompromised patients. Clin Infect Dis 2009; 48:1402.
  53. McLean HQ, Fiebelkorn AP, Temte JL, et al. Prevention of measles, rubella, congenital rubella syndrome, and mumps, 2013: summary recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2013; 62:1.
  54. Kaplan LJ, Daum RS, Smaron M, McCarthy CA. Severe measles in immunocompromised patients. JAMA 1992; 267:1237.
  55. Scott P, Moss WJ, Gilani Z, Low N. Measles vaccination in HIV-infected children: systematic review and meta-analysis of safety and immunogenicity. J Infect Dis 2011; 204 Suppl 1:S164.
  56. Sprauer MA, Markowitz LE, Nicholson JK, et al. Response of human immunodeficiency virus-infected adults to measles-rubella vaccination. J Acquir Immune Defic Syndr 1993; 6:1013.
  57. Wallace MR, Hooper DG, Graves SJ, Malone JL. Measles seroprevalence and vaccine response in HIV-infected adults. Vaccine 1994; 12:1222.
  58. Stermole BM, Grandits GA, Roediger MP, et al. Long-term safety and serologic response to measles, mumps, and rubella vaccination in HIV-1 infected adults. Vaccine 2011; 29:2874.
  59. Aurpibul L, Puthanakit T, Sirisanthana T, Sirisanthana V. Response to measles, mumps, and rubella revaccination in HIV-infected children with immune recovery after highly active antiretroviral therapy. Clin Infect Dis 2007; 45:637.
  60. MacNeil JR, Rubin LG, Patton M, et al. Recommendations for Use of Meningococcal Conjugate Vaccines in HIV-Infected Persons - Advisory Committee on Immunization Practices, 2016. MMWR Morb Mortal Wkly Rep 2016; 65:1189.
  61. Miller L, Arakaki L, Ramautar A, et al. Elevated risk for invasive meningococcal disease among persons with HIV. Ann Intern Med 2014; 160:30.
  62. Harris CM, Wu HM, Li J, et al. Meningococcal Disease in Patients With Human Immunodeficiency Virus Infection: A Review of Cases Reported Through Active Surveillance in the United States, 2000-2008. Open Forum Infect Dis 2016; 3:ofw226.
  63. Cohen C, Singh E, Wu HM, et al. Increased incidence of meningococcal disease in HIV-infected individuals associated with higher case-fatality ratios in South Africa. AIDS 2010; 24:1351.
  64. Simmons RD, Kirwan P, Beebeejaun K, et al. Risk of invasive meningococcal disease in children and adults with HIV in England: a population-based cohort study. BMC Med 2015; 13:297.
  65. Stephens DS, Hajjeh RA, Baughman WS, et al. Sporadic meningococcal disease in adults: results of a 5-year population-based study. Ann Intern Med 1995; 123:937.
  66. Siberry GK, Williams PL, Lujan-Zilbermann J, et al. Phase I/II, open-label trial of safety and immunogenicity of meningococcal (groups A, C, Y, and W-135) polysaccharide diphtheria toxoid conjugate vaccine in human immunodeficiency virus-infected adolescents. Pediatr Infect Dis J 2010; 29:391.
  67. Siberry GK, Warshaw MG, Williams PL, et al. Safety and immunogenicity of quadrivalent meningococcal conjugate vaccine in 2- to 10-year-old human immunodeficiency virus-infected children. Pediatr Infect Dis J 2012; 31:47.
  68. Lujan-Zilbermann J, Warshaw MG, Williams PL, et al. Immunogenicity and safety of 1 vs 2 doses of quadrivalent meningococcal conjugate vaccine in youth infected with human immunodeficiency virus. J Pediatr 2012; 161:676.
  69. Kobayashi M, Farrar JL, Gierke R, et al. Use of 15-Valent Pneumococcal Conjugate Vaccine and 20-Valent Pneumococcal Conjugate Vaccine Among U.S. Adults: Updated Recommendations of the Advisory Committee on Immunization Practices - United States, 2022. MMWR Morb Mortal Wkly Rep 2022; 71:109.
  70. Centers for Disease Control and Prevention (CDC). Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine for adults with immunocompromising conditions: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep 2012; 61:816.
  71. Department of Health and Human Services. Panel on Opportunistic Infections in HIV-Exposed and HIV-Infected Children. Guidelines for the prevention and treatment of opportunistic infections in HIV-exposed and HIV-infected children. Available at: aidsinfo.nih.gov/contentfiles/lvguidelines/oi_guidelines_pediatrics.pdf (Accessed on May 02, 2019).
  72. Prevots DR, Burr RK, Sutter RW, et al. Poliomyelitis prevention in the United States. Updated recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2000; 49:1.
  73. Liang JL, Tiwari T, Moro P, et al. Prevention of Pertussis, Tetanus, and Diphtheria with Vaccines in the United States: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2018; 67:1.
  74. Kurtzhals JA, Kjeldsen K, Heron I, Skinhøj P. Immunity against diphtheria and tetanus in human immunodeficiency virus-infected Danish men born 1950-59. APMIS 1992; 100:803.
  75. Kroon FP, van Dissel JT, Labadie J, et al. Antibody response to diphtheria, tetanus, and poliomyelitis vaccines in relation to the number of CD4+ T lymphocytes in adults infected with human immunodeficiency virus. Clin Infect Dis 1995; 21:1197.
  76. Stanley SK, Ostrowski MA, Justement JS, et al. Effect of immunization with a common recall antigen on viral expression in patients infected with human immunodeficiency virus type 1. N Engl J Med 1996; 334:1222.
  77. Bekker V, Westerlaken GH, Scherpbier H, et al. Varicella vaccination in HIV-1-infected children after immune reconstitution. AIDS 2006; 20:2321.
  78. Son M, Shapiro ED, LaRussa P, et al. Effectiveness of varicella vaccine in children infected with HIV. J Infect Dis 2010; 201:1806.
  79. American Academy of Pediatrics. Committee on Infectious Diseases. Varicella vaccine update. Pediatrics 2000; 105:136.
  80. Levin MJ, Gershon AA, Weinberg A, et al. Immunization of HIV-infected children with varicella vaccine. J Pediatr 2001; 139:305.
  81. Armenian SH, Han JY, Dunaway TM, Church JA. Safety and immunogenicity of live varicella virus vaccine in children with human immunodeficiency virus type 1. Pediatr Infect Dis J 2006; 25:368.
  82. Purswani MU, Karalius B, Yao TJ, et al. Prevalence and Persistence of Varicella Antibodies in Previously Immunized Children and Youth With Perinatal HIV-1 Infection. Clin Infect Dis 2016; 62:106.
  83. Levin MJ, Gershon AA, Weinberg A, et al. Administration of live varicella vaccine to HIV-infected children with current or past significant depression of CD4(+) T cells. J Infect Dis 2006; 194:247.
  84. Edwards KM, Kernodle DS. Possible hazards of routine bacillus Calmette-Guérin immunization in human immunodeficiency virus-infected children. Pediatr Infect Dis J 1996; 15:836.
  85. O'Brien KL, Ruff AJ, Louis MA, et al. Bacillus Calmette-Guérin complications in children born to HIV-1-infected women with a review of the literature. Pediatrics 1995; 95:414.
  86. Armbruster C, Junker W, Vetter N, Jaksch G. Disseminated bacille Calmette-Guérin infection in an AIDS patient 30 years after BCG vaccination. J Infect Dis 1990; 162:1216.
  87. Besnard M, Sauvion S, Offredo C, et al. Bacillus Calmette-Guérin infection after vaccination of human immunodeficiency virus-infected children. Pediatr Infect Dis J 1993; 12:993.
  88. Greenberg RN, Overton ET, Haas DW, et al. Safety, immunogenicity, and surrogate markers of clinical efficacy for modified vaccinia Ankara as a smallpox vaccine in HIV-infected subjects. J Infect Dis 2013; 207:749.
  89. Overton ET, Stapleton J, Frank I, et al. Safety and Immunogenicity of Modified Vaccinia Ankara-Bavarian Nordic Smallpox Vaccine in Vaccinia-Naive and Experienced Human Immunodeficiency Virus-Infected Individuals: An Open-Label, Controlled Clinical Phase II Trial. Open Forum Infect Dis 2015; 2:ofv040.
  90. http://www.cdc.gov/mmwr/pdf/rr/rr5907.pdf (Accessed on January 06, 2011).
  91. Barte H, Horvath TH, Rutherford GW. Yellow fever vaccine for patients with HIV infection. Cochrane Database Syst Rev 2014; :CD010929.
  92. Goujon C, Tohr M, Feuillie V, et al. Good tolerance and efficacy of yellow fever vaccine among subject carriers of human immunodeficiency virus (abstract 32). 4th International Conference on Travel Medicine. International Society of Travel Medicine/World Health Organization, Acapulco, 1995, p. 63.
  93. Veit O, Niedrig M, Chapuis-Taillard C, et al. Immunogenicity and safety of yellow fever vaccination for 102 HIV-infected patients. Clin Infect Dis 2009; 48:659.
  94. Colin de Verdiere N, Durier C, Samri A, et al. Immunogenicity and safety of yellow fever vaccine in HIV-1-infected patients. AIDS 2018; 32:2291.
  95. Pacanowski J, Lacombe K, Campa P, et al. Plasma HIV-RNA is the key determinant of long-term antibody persistence after Yellow fever immunization in a cohort of 364 HIV-infected patients. J Acquir Immune Defic Syndr 2012; 59:360.
Topic 3706 Version 73.0

References