What are the pneumococcal vaccine (Pneumococcal Conjugate Vaccine (PCV) and Pneumococcal Polysaccharide Vaccine (PPSV)) recommendations for Human Immunodeficiency Virus (HIV)-positive individuals?

Pneumococcal Vaccine Recommendations for HIV-Positive Individuals

HIV-positive individuals should receive a single dose of PCV (pneumococcal conjugate vaccine) first, followed by PPSV23 (pneumococcal polysaccharide vaccine) at least 8 weeks later, with a second PPSV23 dose recommended 5 years after the first PPSV23 dose due to their significantly increased risk of invasive pneumococcal disease. 1

Risk Assessment

HIV infection significantly increases the risk of invasive pneumococcal disease (IPD):

• HIV-infected individuals have 122 times higher risk of IPD compared to those without HIV 1
• This elevated risk persists despite immune reconstitution and viral suppression with antiretroviral therapy 2

Current Vaccination Recommendations for HIV-Positive Individuals

For HIV-Positive Adults (19+ years):

1. Initial vaccination (if pneumococcal vaccine-naïve):

   • Administer a single dose of PCV (PCV21, PCV20, or PCV15) first
   • If PCV15 is used, follow with PPSV23 ≥1 year later (or ≥8 weeks later for immunocompromised patients) 1
   • If PCV21 or PCV20 is used, no additional pneumococcal vaccination is needed 1

2. For those who previously received PPSV23 only:

   • Administer a single dose of PCV (PCV21, PCV20, or PCV15) ≥1 year after the last PPSV23 dose 1

3. For those who previously received PCV13 only:

   • Administer a single dose of PCV21, PCV20, or PPSV23
   • If using PCV21 or PCV20, administer ≥1 year after PCV13
   • If using PPSV23, administer ≥8 weeks after PCV13 1

4. For those who received both PCV13 and 1 dose of PPSV23:

   • A single dose of PCV21 or PCV20 (≥5 years after last pneumococcal vaccine), or
   • A second PPSV23 dose (≥8 weeks after PCV13 and ≥5 years after first PPSV23) 1

For HIV-Positive Children:

1. For children aged 6-18 years:

   • Administer a single PCV13 dose first, followed by PPSV23 ≥8 weeks later
   • A second PPSV23 dose is recommended 5 years after the first PPSV23 dose 1

2. For children under 5 years:

   • PCV is recommended for all HIV-infected children aged <5 years
   • Children ≤23 months should follow the routine PCV schedule
   • Children aged 2 years or older should also receive PPSV23 ≥2 months after their last PCV dose 1

Immunogenicity and Efficacy

• Studies show that a combination of PCV followed by PPSV23 provides better immunological response than either vaccine alone in HIV-infected individuals 3
• The pooled seroconversion rate for the PCV/PPSV combination is 57%, compared to 44% for PCV alone and 42% for PPSV alone 3
• A CD4/CD8 ratio >0.8 is associated with better immunological response, while a CD4 nadir <200 cells/μl is associated with poorer response 4
• Undetectable HIV viral load (<40 copies/ml) is significantly associated with better immunological protection 4

Important Clinical Considerations

1. Timing of vaccination:

   • Optimal immunogenicity is achieved when PCV is administered after CD4 count recovery (>200 cells/μl) 3
   • For newly diagnosed HIV patients, consider delaying vaccination until immunological recovery occurs

2. Safety profile:

   • PCVs have demonstrated good safety profiles in HIV-infected individuals
   • Most adverse events are mild to moderate and short in duration 5, 6

3. Duration of protection:

   • More than half of HIV-infected patients maintain immunological protection one year after PCV13 vaccination 4
   • However, long-term durability of the PCV/PPSV combination remains understudied 3

Recent Developments

The introduction of newer pneumococcal conjugate vaccines (PCV15, PCV20, PCV21) offers broader serotype coverage:

• PCV21 and PCV20 can be used as a single dose without the need for subsequent PPSV23 1
• When using PCV15, follow with PPSV23 to provide broader serotype coverage 1

Pitfalls to Avoid

1. Delaying vaccination in eligible patients

   • HIV-infected individuals have 122 times higher risk of IPD compared to those without HIV 1
   • Don't wait for optimal CD4 counts if the patient is at immediate risk

2. Incorrect sequencing of vaccines

   • Always administer PCV before PPSV23 when both are indicated
   • Administering PPSV23 first may result in hyporesponsiveness to subsequent PCV

3. Ignoring vaccination history

   • Always check previous pneumococcal vaccination history to determine the appropriate next steps
   • Different recommendations apply based on previous vaccination status

4. Failing to revaccinate

   • Remember that HIV-positive individuals need a second PPSV23 dose 5 years after the first one