What vaccine is recommended for a 61-year-old male with HIV (Human Immunodeficiency Virus), a history of chicken pox, and uncertain vaccination history?

Recombinant Herpes Zoster Vaccine (Shingrix) is Recommended

This patient should receive the recombinant herpes zoster vaccine (Shingrix), making option C the correct answer. Despite his CD4 count of 185 cells/mm³, which is below the traditional threshold, the recombinant zoster vaccine is non-live and can be safely administered to immunocompromised patients, unlike the older live-attenuated vaccine 1.

Why Recombinant Herpes Zoster Vaccine is Appropriate

Safety in Immunocompromised Patients

• Shingrix is a non-live recombinant vaccine, making it safe for immunocompromised individuals, including those with HIV and low CD4 counts 1, 2
• The live-attenuated zoster vaccine (Zostavax) is absolutely contraindicated in immunocompromised patients due to risk of disseminated VZV infection, but the recombinant vaccine does not carry this risk 1, 3
• For immunocompromised adults aged ≥18 years, the recombinant zoster vaccine is specifically recommended with a shortened dosing schedule (second dose at 1-2 months rather than 2-6 months) 1

High Efficacy and Protection

• Shingrix demonstrates 97.2% efficacy in preventing herpes zoster in adults aged 50 years and older 1
• Protection persists for at least 8 years with minimal waning, maintaining efficacy above 83.3% 1
• This is vastly superior to the older Zostavax vaccine, which had only 18% efficacy in adults ≥80 years 1

History of Chickenpox is Not a Contraindication

• The patient's history of chickenpox as a child actually makes him at risk for herpes zoster reactivation 4
• Shingrix is recommended for all adults aged 50 years and older regardless of prior chickenpox history 2

Why Other Options Are Incorrect

Hepatitis A (Option A) - Not Indicated

• The patient is already immune to hepatitis A as evidenced by positive hepatitis A IgG 5
• Vaccination would provide no additional benefit 5

Varicella (Option B) - Contraindicated

• The patient has a clear history of chickenpox as a child, indicating prior VZV infection and immunity 5
• Varicella vaccination is only considered for HIV-infected persons who are VZV-seronegative 5
• Even if he were seronegative, his CD4 count of 185 cells/mm³ is below the required threshold of >200 cells/mm³ for safe administration of this live vaccine 5
• Live vaccines like varicella are generally avoided in immunocompromised patients 5

Hepatitis B (Option D) - Already Immune

• The patient has positive hepatitis B surface antibody and negative surface antigen, indicating successful prior vaccination or natural immunity 5
• No additional hepatitis B vaccination is needed 5

Clinical Implementation

Dosing Schedule for This Patient

• Administer the first dose of Shingrix now 1
• Give the second dose 1-2 months after the first dose (shortened schedule for immunocompromised patients rather than the standard 2-6 month interval) 1
• The minimum interval between doses is 4 weeks 1

Common Side Effects to Counsel About

• Injection-site reactions (pain, redness, swelling) occur in 9.5% of recipients 1
• Systemic symptoms (myalgia, fatigue, headache) occur in 11.4% of vaccine recipients 1, 6
• No serious safety concerns have been identified in large clinical trials 1

Important Considerations

• The vaccine can be administered regardless of current antiretroviral therapy status 1
• While immune response may be somewhat reduced compared to immunocompetent individuals, the vaccine maintains effectiveness even in patients on immunosuppressive therapy 1
• This patient's age (61 years) places him at increased risk for herpes zoster and its complications, particularly postherpetic neuralgia, making prevention especially important 4, 3