What vaccinations are recommended for a patient with Human Immunodeficiency Virus (HIV)?

Vaccination Recommendations for HIV-Infected Patients

All HIV-infected patients should receive routine inactivated vaccines according to standard schedules, with specific additions including pneumococcal conjugate vaccine (PCV13) followed by pneumococcal polysaccharide vaccine (PPSV23), annual inactivated influenza vaccine, and hepatitis A and B vaccines with post-vaccination serologic testing. 1

Core Inactivated Vaccines (Strongly Recommended)

Pneumococcal Vaccination

• Administer PCV13 first, followed by PPSV23 at least 8 weeks later 1
• For adults with CD4 counts ≥200 cells/μL: strong recommendation for both vaccines 1
• For adults with CD4 counts <200 cells/μL: weaker recommendation but still advised 1
• Revaccinate with PPSV23 after 5 years 1
• If previously vaccinated with PPSV23, give PCV13 at least 1 year after the last PPSV23 dose 1

Influenza Vaccination

• Annual inactivated influenza vaccine (IIV) for all HIV-infected patients aged ≥6 months 1
• Never use live attenuated intranasal vaccine (FluMist) in HIV-infected persons 1
• Exception: Live attenuated vaccine may be considered in otherwise healthy HIV-infected children aged 5-17 years on antiretroviral therapy ≥16 weeks with CD4 percentage ≥15% and HIV RNA <60,000 copies 1

Hepatitis B Vaccination

• Use high-dose hepatitis B vaccine (40 μg/dose) for adults and adolescents 1
• Standard schedule: 3 doses at 0,1, and 6 months 1
• Alternative: 4-dose schedule with double-dose (2 × 20 μg Engerix-B) administered simultaneously 1
• Mandatory post-vaccination testing 1-2 months after completion 1
• If anti-HBs <10 mIU/mL, administer a second 3-dose series using high-dose vaccine 1

Hepatitis A Vaccination

• Two doses at least 6 months apart 1
• Particularly important for men who have sex with men, injection drug users, and those with chronic liver disease or hepatitis B/C co-infection 1

Tetanus-Diphtheria-Pertussis

• One-time Tdap dose, then Td boosters every 10 years 1
• Follow standard immunocompetent schedules 1

Meningococcal Vaccination

• HIV-infected children aged 11-18 years: 2-dose primary series of MCV4 separated by 2 months 1
• Booster dose at age 16 years if primary series given at 11-12 years 1
• For ages 2-10 years with risk factors: 2-dose series with booster after 5 years 1

Human Papillomavirus (HPV) Vaccination

• Quadrivalent HPV vaccine (Gardasil) for males and females aged 11-26 years 1
• Standard 3-dose schedule: 0,2, and 6 months 1
• HPV4 preferred over HPV2 due to activity against genital warts 1

Haemophilus influenzae Type B

• HIV-infected children >59 months who never received Hib: give 1 dose 1
• Not routinely recommended for HIV-infected adults 1

Inactivated Poliovirus Vaccine (IPV)

• Follow standard schedules 1
• Never use oral polio vaccine (OPV) in HIV-infected persons 1

Live Vaccines: Critical Contraindications

Measles-Mumps-Rubella (MMR)

• Contraindicated in severely immunocompromised HIV patients (CD4 <200 cells/mm³ or <15% in children) 1
• May be given to children aged 12 months-13 years with CD4 ≥200 cells/mm³ (≥15%) 1
• Contraindicated in adults and adolescents ≥14 years with severe immunosuppression 1

Varicella Vaccine

• Contraindicated in severely immunocompromised patients (CD4 <200 cells/μL or <15%) 1
• May consider in HIV-infected persons with CD4 ≥200 cells/μL without evidence of immunity: 2 doses 3 months apart 1
• Strong recommendation for children aged 1-8 years with adequate CD4 counts 1

Zoster Vaccine

• Contraindicated in HIV-infected patients regardless of CD4 count 1
• May consider in patients >60 years with CD4 ≥200 cells/μL, though safety and efficacy unknown 1

Rotavirus Vaccine

• Can be given to HIV-exposed infants with unknown HIV status 1
• Weak recommendation for HIV-infected infants 1

Timing Considerations Based on CD4 Count

Optimal Vaccination Window

• Administer vaccines as early as possible in HIV infection when CD4 counts are higher 2
• Pneumococcal vaccine response significantly better in asymptomatic persons with preserved immunity 2
• For CD4 ≥200 cells/μL: proceed with all recommended inactivated vaccines 1

Severely Immunocompromised (CD4 <200 cells/μL)

• Still administer inactivated vaccines, though response may be suboptimal 1
• Absolutely avoid all live vaccines 1
• Consider delaying non-urgent vaccines until immune reconstitution on antiretroviral therapy 3

Special Populations

Children and Adolescents

• Follow CDC childhood immunization schedules with modifications noted above 1
• HIV-infected infants should receive all routine inactivated vaccines 1
• Two-dose influenza series for children <9 years receiving vaccine for first time 1

Pregnant Women

• Td may be administered after 20 weeks gestation or immediately postpartum 1
• Inactivated vaccines generally safe during pregnancy 1

Common Pitfalls to Avoid

• Do not assume adequate immunity without post-vaccination testing for hepatitis B 1
• Do not give live vaccines to household contacts who are severely immunocompromised (exception: healthy contacts may receive LAIV) 1
• Do not delay pneumococcal vaccination—give PCV13 first, not PPSV23 1
• Do not skip annual influenza vaccination even if prior response was poor 1
• Do not use standard-dose hepatitis B vaccine—use high-dose formulation 1

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