Should Human Immunodeficiency Virus (HIV) patients over 26 years old receive the Human Papillomavirus (HPV) vaccine?

HPV Vaccination for HIV-Positive Patients Over Age 26

HIV-positive patients aged 26 years and older should receive HPV vaccination as they can benefit from it despite being outside the routine vaccination age range. 1

Recommendation Framework

The recommendation for HPV vaccination in HIV-positive individuals over age 26 is based on:

1. Strong evidence for increased risk: HIV-infected individuals have significantly higher rates of HPV-related cancers and diseases compared to the general population:

   • Anal cancer incidence: 131/100,000 person-years in HIV-positive MSM (80.3 times higher than HIV-negative men) 1
   • Higher prevalence of condylomata (genital warts): 28% in HIV-positive MSM and 15% in HIV-positive heterosexual men 1

2. Expert consensus guidelines: The multidisciplinary, evidence-based consensus guidelines explicitly state that "HIV-positive patients aged ≥ 26 years may also benefit from HPV vaccination" 1

Vaccination Protocol for HIV-Positive Adults

• Dosing schedule: 3-dose series (0,1-2,6 months) regardless of age at initiation 2
• Vaccine type: Quadrivalent or nonavalent vaccines are preferred given the high prevalence of anogenital warts in HIV patients 1
• Timing considerations: Ideally, patients should be on antiretroviral treatment with good immune-virological control at the time of vaccination 1

Clinical Considerations

Efficacy in HIV-Positive Populations

While direct efficacy data in HIV-positive adults over 26 is limited:

• HPV vaccines have demonstrated safety and immunogenicity in HIV-positive populations 3
• Increased immunogenicity has been reported in persons on antiretroviral therapy compared to antiretroviral-naïve persons 3
• The quality of evidence for vaccination in HIV-positive adults over 26 is rated as "low" but the recommendation remains "weak" in favor of vaccination 1

Implementation Considerations

• CD4 count: No clear association has been found between CD4+ cell count at immunization and vaccine response, though better immune control is preferred 3
• Prior HPV exposure: Even with likely prior exposure, vaccination may provide protection against HPV types not yet acquired 2
• Continued screening: HPV vaccination does not replace the need for regular cervical cancer screening and other preventive measures 2

Potential Pitfalls and Caveats

1. Efficacy limitations: Vaccine effectiveness may be lower in older adults due to likely prior HPV exposure 2
2. Established infections: The vaccines are prophylactic only and will not treat existing HPV infections or HPV-related disease 2
3. Ongoing research: Several trials are still evaluating vaccine efficacy against disease endpoints in HIV-infected populations 3

Summary

For HIV-positive patients over age 26, HPV vaccination is recommended despite being outside the routine age range. The increased risk of HPV-related cancers in this population justifies vaccination even when the evidence quality is rated as "low." The 3-dose schedule should be used, preferably with quadrivalent or nonavalent vaccines, and administered when the patient has good immunological control on antiretroviral therapy.