What are the pneumonia vaccine recommendations for Human Immunodeficiency Virus (HIV) patients?

Pneumococcal Vaccination Recommendations for HIV Patients

HIV-infected adults should receive one dose of PCV20 alone, or one dose of PCV15 followed by a dose of PPSV23 at least 1 year later (with a shorter interval of ≥8 weeks considered for immunocompromised patients). 1

Current Recommendations

The Advisory Committee on Immunization Practices (ACIP) provides clear guidance for pneumococcal vaccination in HIV-infected individuals:

1. Primary vaccination options for pneumococcal vaccine-naïve HIV patients:

   • One dose of 20-valent pneumococcal conjugate vaccine (PCV20) alone
   • OR
   • One dose of 15-valent pneumococcal conjugate vaccine (PCV15) followed by a dose of 23-valent pneumococcal polysaccharide vaccine (PPSV23) 1

2. Timing between doses:

   • For most HIV patients, the interval between PCV15 and PPSV23 should be ≥1 year
   • For HIV patients (who are immunocompromised), a shorter interval of ≥8 weeks may be beneficial 1

3. CD4 count considerations:

   • Vaccination is recommended regardless of CD4 count
   • However, immune responses are likely to be stronger with higher CD4 counts 2

Rationale and Evidence

HIV-infected individuals remain at significantly higher risk for pneumococcal disease despite antiretroviral therapy. The risk of invasive pneumococcal disease in HIV-infected adults is up to 40 times higher than in healthy adults, even with herd protection from childhood vaccination programs 1.

Research demonstrates:

• PCV vaccines produce stronger immune responses in HIV patients compared to polysaccharide vaccines 3
• A single dose of PCV13 induces significant immune responses in HIV patients with CD4 counts >200 cells/μL 2
• CD4/CD8 ratio >0.8 is associated with better immunological response 2
• Undetectable HIV viral load (<40 copies/ml) is associated with better protection 2

Historical Context

Previous guidelines (2014) from the HIV Medicine Association of IDSA recommended that HIV patients "should receive a dose of PCV13 (Prevnar 13), followed by a dose of PPV23 (Pneumovax) at least 8 weeks later. If previously vaccinated with PPV23, give PCV13 at least 1 year after PPV23." 1

The evolution to the current recommendations reflects improved understanding of conjugate vaccine efficacy and expanded valency options.

Special Considerations

Timing After Previous Vaccination

• If a patient previously received PPSV23, wait at least 1 year before administering PCV13/PCV15/PCV20 1
• Studies suggest waiting longer than 1 year after PPSV23 may slightly improve antibody response to subsequent PCV vaccination 4

CD4 Count Impact

• Higher CD4 counts are associated with better post-vaccination antibody concentrations 2
• CD4 nadir <200 cells/μL is associated with poorer immunological response 2
• However, vaccination should not be delayed in patients with low CD4 counts, as some protection is still conferred

Durability of Protection

• More than half of HIV patients maintain immunological protection one year after PCV13 vaccination 2
• A second dose of PPSV23 is recommended 5 years after the first PPSV23 dose 1

Common Pitfalls to Avoid

1. Delaying vaccination until CD4 counts improve - vaccination should be administered regardless of CD4 count
2. Failing to revaccinate - consider a second PPSV23 dose 5 years after the first PPSV23 dose
3. Using incorrect intervals between vaccines - shorter intervals (≥8 weeks) are appropriate for HIV patients between PCV15 and PPSV23
4. Not checking vaccination history - different recommendations apply for those previously vaccinated with PPSV23

Practical Implementation

1. For pneumococcal vaccine-naïve HIV patients:

   • Administer PCV20 alone
   • OR
   • Administer PCV15 followed by PPSV23 after ≥8 weeks (immunocompromised) or ≥1 year (others)

2. For HIV patients previously vaccinated with PPSV23:

   • Administer PCV13/PCV15/PCV20 at least 1 year after the most recent PPSV23 dose

3. For HIV patients who received PCV13 under previous guidelines:

   • Complete the series with PPSV23 if not already given
   • Consider PCV20 for broader coverage if appropriate interval has passed since previous vaccination

The goal of these recommendations is to reduce the significant morbidity and mortality associated with pneumococcal disease in HIV-infected individuals.