What is the best recommendation for a 32-year-old male with well-controlled Human Immunodeficiency Virus (HIV) on bictegravir (integrase strand transfer inhibitor)/emtricitabine (nucleoside reverse transcriptase inhibitor)/tenofovir alafenamide (nucleotide reverse transcriptase inhibitor) therapy, with an HIV RNA level of less than 20 copies per milliliter and a CD4 count of 300 cells per cubic millimeter, regarding yellow fever vaccination prior to international travel?

Yellow Fever Vaccination in HIV-Positive Patient with CD4 Count of 300 cells/mm³

Vaccination with standard dose yellow fever vaccine is permissible 12 days before the trip (Option A).

Patient Classification and Risk Assessment

This patient falls into the category of asymptomatic HIV infection with moderate immune suppression (CD4 count 200-499 cells/mm³), which is classified as a precaution rather than a contraindication for yellow fever vaccination 1.

Key Clinical Context:

• Virologically suppressed (HIV RNA <20 copies/mL) on effective antiretroviral therapy 1
• CD4 count of 300 cells/mm³ places him in the moderate immunosuppression category (200-499 cells/mm³) 1
• Asymptomatic with stable immune reconstitution on treatment 1

Vaccination Recommendation

Standard dose vaccination is appropriate - there is no evidence supporting double-dose yellow fever vaccination in any population, including immunocompromised individuals 1. The ACIP guidelines explicitly state that vaccination "can be considered" for asymptomatic HIV-infected persons with moderate immune suppression traveling to yellow fever endemic areas 1.

Safety Profile in This Population:

• Multiple retrospective and prospective studies including approximately 450 HIV-infected persons reported no serious adverse events among patients with moderate immunosuppression based on CD4 counts 1
• The absolute contraindication applies only to severe immunosuppression (CD4 <200 cells/mm³ or <15% of total lymphocytes) 2

Timing Considerations

The 12-day interval is critical because:

• Yellow fever vaccine induces low-level viremia in primary vaccines, which abates as anti-yellow fever virus IgM antibodies develop 4 to 7 days post-vaccination 1
• Protective immunity requires adequate time for antibody development before potential exposure 1
• The 5-day interval (Options B and D) is insufficient for optimal immune response development 1

Important Caveats and Monitoring

Reduced Immunogenicity:

• HIV-infected persons demonstrate reduced immunologic response to yellow fever vaccine compared to HIV-negative individuals 1
• In one retrospective cohort study, only 83% (65/78) of HIV-infected persons developed specific antibodies against yellow fever virus in the first year after vaccination, compared to 97% (64/66) of HIV-uninfected persons (p=0.01) 1
• Measurement of neutralizing antibody response should be considered before travel by contacting the state health department or CDC (1-970-221-6400) 1

Post-Vaccination Monitoring:

• Vaccinated persons should be monitored closely after vaccination for evidence of adverse events 1
• If an adverse event occurs, a VAERS report should be filed and the state health department or CDC should be notified 1

Special Consideration for Antiretroviral Regimen:

• This patient is on bictegravir (an integrase inhibitor), not a CCR5-receptor antagonist 1
• One case of vaccine-associated viscerotropic disease (YEL-AVD) was reported in a person with a genetic polymorphism in chemokine receptor CCR5, raising theoretical concerns about CCR5-receptor antagonists, but this does not apply to this patient's regimen 1

Alternative: Medical Waiver

If international travel requirements rather than actual risk of yellow fever exposure are the only reason for vaccination, the patient should be excused from vaccination and issued a medical waiver to fulfill health regulations 1. This decision should be based on:

• Destination-specific yellow fever risk assessment 1
• Whether the trip involves actual exposure risk versus administrative requirements 1
• Emphasis on protective measures against mosquito bites if vaccination is deferred 1