At what age should a person living with Human Immunodeficiency Virus (HIV) receive the shingles vaccine?

Shingles Vaccination for People Living with HIV

People living with HIV (PLWH) should receive the recombinant zoster vaccine (Shingrix) starting at age 18 years, regardless of CD4 count, as they are considered at increased risk for herpes zoster. 1

Vaccination Recommendations for PLWH

Age-Based Recommendations

• Ages 18-49 years: PLWH are specifically recommended to receive Shingrix as they fall under the "increased risk due to immunodeficiency" category 1
• Ages 50+ years: Recommended for all adults, including PLWH 1

Dosing Schedule

• Standard schedule: Two doses of Shingrix (0.5 mL each)
• Timing for PLWH: Doses should be administered 1-2 months apart (shortened interval for immunocompromised patients) 1
• Administration route: Intramuscular injection

CD4 Count Considerations

• Shingrix (recombinant zoster vaccine or RZV) is safe for PLWH regardless of CD4 count
• This is in contrast to the older live attenuated herpes zoster vaccine (Zostavax), which was only recommended for PLWH with CD4 counts >200 cells/μL 2

Rationale for Early Vaccination in PLWH

1. Higher disease burden: PLWH have an increased incidence of herpes zoster and post-herpetic neuralgia compared to age-matched general population, even with effective antiretroviral therapy 3

2. Persistent immune dysfunction: PLWH may exhibit sustained immune dysfunction despite viral suppression and normal CD4 counts 3

3. Superior vaccine efficacy: Shingrix demonstrates high efficacy (>90%) across all age groups and is specifically recommended for immunocompromised patients 1

Implementation Considerations

Vaccine Series Completion

• Completing the full two-dose series is crucial for optimal protection
• Real-world studies show two-dose effectiveness at 70.1% compared to 56.9% for a single dose 1
• Approximately 80% of patients complete the series within 12 months of the first dose 4

Co-administration with Other Vaccines

• Shingrix can be administered with other vaccines such as influenza or pneumococcal vaccines 1
• No minimum interval is required between Shingrix and other vaccines

Prior Vaccination or Herpes Zoster History

• Previous vaccination with Zostavax is not a contraindication; Shingrix can be administered after a minimum interval of 8 weeks 1
• No need to wait after a shingles episode before receiving Shingrix 1

Common Pitfalls to Avoid

1. Delaying vaccination: Don't wait until age 50 for PLWH; they should receive Shingrix starting at age 18 due to their increased risk 1

2. Missing the second dose: Ensure patients understand the importance of returning for the second dose to achieve optimal protection 1

3. Unnecessary screening: No serologic testing for varicella immunity is needed before vaccination 1

4. Using live zoster vaccine: The older live vaccine (Zostavax) is not recommended for PLWH with CD4 counts <200 cells/μL; Shingrix is preferred for all PLWH 2

By following these guidelines, healthcare providers can help reduce the burden of herpes zoster and its complications in people living with HIV through appropriate and timely vaccination.