Can an HIV patient on Biktarvy (bictegravir/emtricitabine/tenofovir alafenamide) receive the herpes zoster vaccine?

Herpes Zoster Vaccination in HIV Patients on Biktarvy

Yes, HIV patients on Biktarvy can receive herpes zoster vaccine, specifically the recombinant zoster vaccine (Shingrix/RZV), which is strongly recommended for HIV-infected adults regardless of CD4 count, though optimal response occurs when CD4 ≥200 cells/mm³ and viral suppression is achieved. 1

Vaccine Selection and Recommendations

Recombinant Zoster Vaccine (RZV/Shingrix) - Preferred Option

RZV is the recommended herpes zoster vaccine for HIV-infected adults because it is an inactivated subunit vaccine that is both safe and effective in immunocompromised populations. 1

Key advantages of RZV in HIV patients:

• Demonstrated safety and immunogenicity in HIV-infected adults across all CD4 strata, including those with CD4 counts as low as 50-199 cells/mm³ 2
• No risk of vaccine-strain viral infection since it contains only glycoprotein E antigen, not live virus 2
• Produces robust humoral and cellular immune responses that persist through at least 18 months 2
• No vaccination-related serious adverse events or sustained impact on HIV viral load or CD4 counts 2

Optimal Timing for RZV Administration

For best immune response, consider deferring vaccination until the patient is virologically suppressed on antiretroviral therapy with CD4 ≥200 cells/mm³, though vaccination can be given at lower CD4 counts if clinically indicated. 1

• Patients on Biktarvy who achieve viral suppression (HIV-1 RNA <50 copies/mL) are ideal candidates, as this occurs in >94% of patients by 12 months 3, 4
• Higher CD4 counts correlate with better antibody responses to vaccination 1

Live Attenuated Zoster Vaccine (ZVL/Zostavax) - Alternative with Restrictions

ZVL may be considered only for HIV patients with CD4 ≥200 cells/mm³ who are virologically suppressed on ART, though RZV remains preferred. 1, 5, 6

Critical safety considerations for ZVL:

• Contraindicated in highly immunocompromised patients (CD4 <200 cells/mm³) due to risk of disseminated vaccine-strain VZV infection 1, 5
• Contains approximately 14 times the potency of varicella vaccine 5
• In clinical trials of 295 HIV-infected adults with CD4 >200 cells/mm³, ZVL was safe and immunogenic with no vaccine-strain infections 6
• Must be used within 30 minutes of reconstitution 5

Clinical Algorithm for Herpes Zoster Vaccination in HIV Patients on Biktarvy

Step 1: Assess Current HIV Control

• Check most recent CD4 count and HIV viral load 1
• Confirm patient is adherent to Biktarvy (which provides excellent viral suppression in >94% of patients) 3, 4

Step 2: Select Appropriate Vaccine

• If CD4 ≥200 cells/mm³ and virologically suppressed: Administer RZV (2 doses, 2-6 months apart) - PREFERRED 1
• If CD4 <200 cells/mm³: Administer RZV only (ZVL is contraindicated) 1, 5
• If CD4 50-199 cells/mm³: RZV has been studied and is safe, though immune response may be somewhat reduced 2

Step 3: Administration

• RZV: Give 2 doses intramuscularly, 2-6 months apart 1
• Expect high rates of injection site reactions (>80%) but these are generally mild and self-limited 1
• No need to adjust Biktarvy dosing or timing 7

Important Caveats and Pitfalls

Common Pitfall: Assuming all live vaccines are contraindicated in HIV patients on effective ART. While ZVL requires CD4 >200 cells/mm³, RZV (the preferred vaccine) can be given at any CD4 count. 1, 2

Drug Interaction Consideration: Biktarvy has no known interactions with herpes zoster vaccines, and the integrase inhibitor component (bictegravir) has a high genetic barrier to resistance, making treatment interruption unnecessary. 7

Monitoring After Vaccination: No sustained impact on HIV viral load or CD4 counts has been observed following RZV vaccination, so routine additional monitoring beyond standard HIV care is not required. 2

Timing with Other Vaccines: RZV can be administered concomitantly with other inactivated vaccines (influenza, pneumococcal) without compromising immunogenicity. 1

Special Considerations for Biktarvy Patients

Biktarvy provides excellent virologic control with 94-97% of patients achieving undetectable viral loads, making most patients on this regimen ideal candidates for herpes zoster vaccination. 3, 4

• No treatment-emergent resistance has been reported with Biktarvy, ensuring stable immune reconstitution 7, 4
• The regimen is well-tolerated with low discontinuation rates (5-6%), supporting consistent ART adherence needed for optimal vaccine response 3, 4
• Biktarvy can be used in patients with renal impairment (CrCl ≥30 mL/min), and vaccination recommendations remain unchanged in this population 7