What is the best recommendation for pneumococcal vaccination in a patient with Human Immunodeficiency Virus (HIV) who received one dose of pneumococcal conjugate vaccine (PCV20) one year prior?

Pneumococcal Vaccination Recommendation for HIV-Positive Patient After PCV20

The patient does not require any additional doses of any pneumococcal vaccination (Answer B). 1

Rationale Based on Current ACIP Guidelines

For adults with HIV who have received a single dose of PCV20, the pneumococcal vaccination series is complete and no additional doses are needed. 1 This represents a significant simplification from previous recommendations that required sequential vaccination with both conjugate and polysaccharide vaccines.

Key Evidence Supporting This Recommendation

• PCV20 provides comprehensive serotype coverage that eliminates the need for subsequent PPSV23 administration, even in immunocompromised patients like those with HIV 1

• The 2023 ACIP guidelines explicitly state that when PCV20 is used in adults with immunocompromising conditions (including HIV), it need not be followed by additional pneumococcal vaccine doses 1

• The 2024 ACIP update reinforced this recommendation, confirming that PCV20 alone completes the pneumococcal vaccination series for adults with HIV 1

Why Other Options Are Incorrect

Option A (PPSV23 Today) - Incorrect

• PPSV23 is not indicated after PCV20 administration 1
• The broader serotype coverage of PCV20 (20 serotypes) combined with the superior immunologic properties of conjugate vaccines makes additional PPSV23 unnecessary 1

Option C (PPSV23 in Four Years) - Incorrect

• This would have been appropriate if the patient had received PCV13 or PCV15, but not after PCV20 1
• The old sequential PCV13-PPSV23 strategy has been replaced by single-dose PCV20 1

Option D (PPSV23 at Age 65) - Incorrect

• No additional pneumococcal vaccines are recommended at age 65 for patients who have already received PCV20, regardless of HIV status 1, 2
• The vaccination series is complete after PCV20 1, 3

Important Clinical Context for HIV Patients

HIV-infected adults are at significantly higher risk for invasive pneumococcal disease and are classified as having an immunocompromising condition requiring pneumococcal vaccination 1, 2, 3

Historical Context

• Prior to 2022, HIV patients required sequential vaccination with PCV13 followed by PPSV23 at 8-week intervals 1, 4
• The introduction of PCV20 simplified this to a single-dose regimen 1

Common Pitfall to Avoid

Do not administer PPSV23 after PCV20 based on outdated protocols. 1 Many clinicians may reflexively add PPSV23 for immunocompromised patients, but this is no longer indicated when PCV20 has been used 1, 3

Documentation Recommendation

Document in the patient's record that:

• Pneumococcal vaccination series is complete with PCV20 1
• No additional pneumococcal vaccines are needed unless future guidelines change 1, 3
• Vaccination status should be reviewed if the patient undergoes hematopoietic stem cell transplant, which would require revaccination 1