From the Guidelines
HIV-positive individuals with severe immunosuppression should avoid live vaccines due to the risk of vaccine-induced disease, but those with CD4 counts above 200 cells/mm³ and on effective antiretroviral therapy may safely receive certain live vaccines after careful risk-benefit assessment. The decision to administer live vaccines to HIV-infected patients depends on their current immune status, risk of exposure to the disease, and potential consequences of infection 1.
Key Considerations
- Live vaccines such as MMR, varicella, yellow fever, and oral typhoid should be avoided when the CD4 count is below 200 cells/mm³ 1.
- The MMR vaccine can be given to HIV-positive adults with CD4 counts above 200 cells/mm³, while the yellow fever vaccine requires special consideration and should only be administered when truly necessary and when CD4 counts exceed 200 cells/mm³ 1.
- Inactivated vaccines are safe for all HIV patients regardless of CD4 count, though immune response may be suboptimal in those with severe immunosuppression 1.
Specific Vaccine Recommendations
- HIV-infected children aged 1–13 years without severe immunosuppression should receive the MMR vaccine 1.
- HIV-infected patients should receive the HepB vaccine series, with consideration of high-dose HepB vaccine for adults and adolescents 1.
- HIV-exposed or -infected infants should receive rotavirus vaccine according to the schedule for uninfected infants 1.
- HIV-infected patients should not receive LAIV 1.
Individualized Vaccination Decisions
Each vaccination decision should be individualized based on the patient's current immune status, risk of exposure to the disease, and potential consequences of infection 1.
From the Research
HIV and Live Vaccines
- Live vaccines are contraindicated for people with HIV (PWH) with CD4+ counts less than 200 cells/μL or uncontrolled HIV 2.
- The use of live attenuated herpes zoster vaccine (LAHZV) is recommended for HIV-infected adults with a CD4 count above 200 cells/μL 3.
- Varicella vaccine is recommended in varicella-susceptible adults with HIV infection, as long as they have a CD4 count > 200 cells/μL 3, 4.
- HIV-infected children with a CD4(+) T cell percentage of > or =15% and a CD4(+) T cell count of > or =200 cells/ microL are likely to benefit from receiving varicella vaccine 4.
- Live vaccines, such as MMR and yellow fever vaccines, are also recommended for people with HIV infection, but with the same CD4 threshold of > 200 cells/μL 3.
Safety and Immunogenicity
- LAHZV was administered to 295 HIV-infected adults with a CD4 count > 200 cells/μL, and was safe and immunogenic with no cases of vaccine strain infection 3.
- The varicella vaccine was well tolerated in HIV-infected children with moderate symptoms and/or more pronounced past or current decreases in CD4(+) T cell counts, with no vaccine-related, serious adverse events 4.
- Regardless of immunologic category, at least 79% of HIV-infected vaccine recipients developed VZV-specific antibody and/or CMI 2 months after 2 doses of vaccine, and 83% were responders 1 year after vaccination 4.
Vaccination Recommendations
- Vaccinations for influenza, COVID-19, herpes zoster (shingles), hepatitis B, meningococcal disease, mpox, and human papillomavirus are recommended for PWH 2.
- The Advisory Committee on Immunization Practices has released recommendations incorporating the newer formulations of the pneumococcal pneumonia and respiratory syncytial virus vaccines 2.
- Additional considerations for the timing of vaccinations are described, including whether to delay vaccination until improvement of the immune status 2.