Purpose of This Guideline

Date of current publication: April 2, 2024 Lead authors: Christine Kerr, MD; Mary Dyer, MD Contributor: Marguerite A. Urban, MD Writing group: Rona M. Vail, MD, AAHIVS; Sanjiv S. Shah, MD, MPH, AAHIVM, AAHIVS; Steven M. Fine, MD, PhD; Joseph P. McGowan, MD, FACP, FIDSA, AAHIVS; Samuel T. Merrick, MD, FIDSA; Asa E. Radix, MD, MPH, PhD, FACP, AAHIVS; Jessica Rodrigues, MPH, MS; Christopher J. Hoffmann, MD, MPH, MSc, FACP; Brianna L. Norton, DO, MPH; Charles J. Gonzalez, MD Committee: Medical Care Criteria Committee Date of original publication: December 15, 2022

This compendium of immunization recommendations for adults (≥18 years) with HIV was compiled by the New York State Department of Health AIDS Institute (NYSDOH AI) to assist clinical practitioners in New York State who provide primary care to adults with HIV. The goal is to present a single compilation of all routine vaccinations for adults with HIV recommended by the Centers for Disease Control and Prevention (CDC), National Institutes of Health (NIH), HIV Medicine Association (HIVMA) [DHHS 2022], and the Infectious Disease Society of America [Thompson, et al. 2021]. The European AIDS Clinical Society guidelines were also consulted [EACS 2021]. Where a recommendation differs from these source documents, the rationale is provided.

This document also discusses published literature related to specific vaccines and the rationale for recommendations for which there is no consensus among the referenced guidelines, no evidence specific to patients with HIV, or new data have been published.

Considerations and Contraindications

The tables and accompanying discussion in this guideline compile recommendations, vaccination schedules, clinical comments, and sources from the Centers for Disease Control and Prevention (CDC), National Institutes of Health, and HIV Medicine Association guidelines [DHHS 2022], the Infectious Diseases Society of America [Thompson, et al. 2021], and the European AIDS Clinical Society [EACS 2021].

Immunizations against infectious diseases are a particularly important component of care for individuals with HIV. Immunodeficiency reduces natural defenses to vaccine-preventable diseases in people with HIV and places them at increased risk for disease and for severe disease [Thompson, et al. 2021; Crum-Cianflone and Wallace 2014]. However, there is concern that individuals with HIV-associated immunodeficiency may not be able to mount and maintain an appropriate immune response to vaccines and may be harmed by live virus vaccines. The strength of the immune response may be lower in adults with advanced HIV, especially those with CD4 counts <200 cells/mm³ and/or HIV RNA levels (viral loads) ≥200 copies/mL, and shorter in duration than in adults without HIV [Crum-Cianflone and Wallace 2014]. Immunogenicity, vaccine response monitoring, and requirements for additional booster doses for patients with HIV are discussed on pages for individual vaccines.

Inactivated vaccines are generally considered safe, although data are insufficient to rule out rare adverse effects [ACIP 2022; Thompson, et al. 2021]. Live, attenuated vaccines are contraindicated for patients with CD4 counts <200 cells/mm³, because of the risk of severe reactions in individuals who are immunosuppressed [CDC 1996; Redfield, et al. 1987; CDC 1985; Davis, et al. 1977]. For patients with HIV and CD4 counts ≥200 cells/mm³, inactivated forms of vaccines such as those for polio, influenza, typhoid, and zoster are preferred over the live vaccine options. Live, attenuated vaccines should be administered only when an inactivated version does not exist and the risk of the disease clearly outweighs the theoretical risk of vaccination.

Transient increases in viral load and decreases in CD4 cell count caused by immune system activation have been described after vaccination in patients with HIV in some older studies [Kolber, et al. 2002; Rey, et al. 2000]. The changes are less likely to occur in patients taking antiretroviral therapy and have not been found to have long-term negative effects [Thompson, et al. 2021; Sullivan, et al. 2000]. In people older than 5 years with HIV, effective ART is defined as ART taken for ≥6 months, with a CD4 percentage ≥15% and a CD4 count ≥200 cells/mm³ for ≥6 months [McLean, et al. 2013]. Viral suppression is defined as an HIV RNA level (viral load) <200 copies/mL.

Clinicians should advise their patients with HIV that family members, close contacts, and other household members should receive all age-appropriate vaccinations, including an annual influenza vaccine, to reduce the patients’ exposure to vaccine-preventable diseases [Thompson, et al. 2021; Grohskopf, et al. 2019; Fiore, et al. 2011]. Live, attenuated virus vaccines may be safely administered to close contacts of individuals with HIV, with specific precautions for varicella and rotavirus vaccines. Transmission of live, attenuated virus after vaccination is rare [Thompson, et al. 2021]. However, patients with HIV who lack varicella immunity are advised to avoid direct contact with people who develop a rash after varicella or zoster vaccination. [Thompson, et al. 2021; Fiore, et al. 2011; Cortese and Parashar 2009; Marin, et al. 2007].

The tables in this guideline (for each vaccine listed) present the recommended immunizations for adults with HIV, followed by discussion of each. For complete vaccination recommendations, see the CDC Immunization Schedules and the vaccine manufacturers’ package inserts.

COVID-19

Universal vaccination: To reduce community transmission and protect individuals with HIV, this committee agrees with the CDC recommendations for universal vaccination against COVID-19 for adults (≥18 years old) with HIV, regardless of prior history of COVID-19 infection. This committee also agrees with the CDC’s recommendation that people with HIV with active viremia or with a CD4 count <200 cells/mm³ should be vaccinated as per the CDC’s schedule for moderately or severely immunocompromised patients. Schedules for all patients include at least 1 bivalent vaccination dose, even if they have completed a monovalent vaccine dosing schedule.

The available vaccines against SARS-CoV-2 have strong evidence both for safety and efficacy in preventing severe disease and death [Grana, et al. 2022]. Additionally, many people with HIV have multiple risk factors for severe COVID-19 infection. For more information, see:

• CDC: COVID-19: Understanding Risk
• NYC Health: COVID-19: Prevention and Groups at Higher Risk > People at Increased Risk of Severe Illness
• U.S. Department of Health and Human Services: Guidance for COVID-19 and People With HIV
• National Institutes of Health: COVID-19 Treatment Guidelines: Special Considerations in People With HIV

Discussion: COVID-19 morbidity and mortality are increased among individuals of older age and who have comorbidities that put them at high risk of severe disease [Bhaskaran, et al. 2021; Costenaro, et al. 2021; Mirzaei, et al. 2021; Patel, et al. 2021; Tesoriero, et al. 2021; Cooper, et al. 2020; Nandy, et al. 2020; Ssentongo, et al. 2020]. Although initial studies of HIV and COVID-19-related mortality found conflicting results, a World Health Organization report based on results from 37 countries found a 30% increased risk of severe illness at time of hospital admission and an in-hospital mortality rate of 23.1% for people with HIV [WHO 2021]. Because there is also an increased risk of COVID-19 infection, whether due to overlapping comorbidities or disease-specific factors, people with HIV are a high-priority group for vaccination [Mellor, et al. 2021; Patel, et al. 2021; Ssentongo, et al. 2021; Byrd, et al. 2020].

COVID-19 vaccines have been shown to be safe and highly effective at reducing severe illness, hospitalization, and mortality. Common mild adverse effects include injection site pain, headache, fatigue, myalgias, fever, and nausea. Rarely, more serious allergic reactions can occur. Myocarditis has been reported mostly among young men, mostly after the second dose of an mRNA vaccine, and has been mostly mild with spontaneous resolution (see CDC: Myocarditis and Pericarditis Considerations).

COVID-19 vaccines have been shown to be safe and effective in people with HIV [Yin, et al. 2022]. There has been no evidence of decreased vaccine efficacy and no reports of increased vaccine adverse effects in people with HIV, although antibody response may peak later and wane earlier [Fowokan, et al. 2023; Chambers, et al. 2022]. However, individuals with HIV and a CD4 count <350 cells/mm³ are at high risk for breakthrough infection and should receive vaccination as per the schedule for patients who are immunocompromised [Lang, et al. 2022].

Haemophilus influenzae Type B (Hib)

Discussion: Hib vaccination is not routinely recommended for patients with HIV in the absence of other risk factors, such as anatomic or functional asplenia, sickle cell disease, or hematopoietic stem cell transplant, because there is a low risk of Hib infection in adults with HIV [CDC 2023; Thompson, et al. 2021; Briere, et al. 2014]. Data on the safety and efficacy of the Hib vaccine among adults with HIV indicate a strong immune response, similar to that in adults without HIV, except among those with severe immunosuppression [MacLennan, et al. 2016; Dockrell, et al. 1999; Kroon, et al. 1997; Steinhoff, et al. 1991].

Hepatitis A Virus (HAV)

Discussion: The HAV vaccine is recommended for all adults with HIV who do not have immunity to HAV [CDC(a) 2022; Thompson, et al. 2021].

The reported rate of HAV antibody seroconversion after vaccination ranges from 49% to 96% [Mena, et al. 2015; Crum-Cianflone and Wallace 2014; Fiore, et al. 2006]. A long-term follow-up study reported that more than 85% of individuals who seroconverted after vaccination had a sustained antibody response for 5 to 10 years [Cheng, et al. 2017; Crum-Cianflone(b), et al. 2011]. Although immunocompetent individuals with HIV respond to the HAV vaccine nearly as well as individuals without HIV, individuals with lower CD4 cell counts are less likely to acquire protective levels of antibody [Mena, et al. 2015; Crum-Cianflone and Wallace 2014; Fiore, et al. 2006].

If a patient’s CD4 count is <200 cells/mm³ or the patient has symptomatic HIV, it is preferable to defer vaccination until several months after initiation of antiretroviral therapy to maximize the antibody response to the vaccine [DHHS 2022]. HAV vaccination should not be deferred in patients who are unlikely to achieve an increased CD4 cell count.

Care providers should perform HAV immunoglobulin G (IgG) testing at least 1 month after the final dose of the vaccination series to confirm immune response. HAV vaccination should be repeated in patients with no response to initial vaccination, [Thompson, et al. 2021], and they should be counseled to avoid exposure to HAV because they remain susceptible to infection, although a small study reported that 31% of participants who had not seroconverted at month 12 and before month 18 (n = 16) subsequently seroconverted after completing the 2-dose vaccination series [Cheng, et al. 2017]. If a patient is susceptible to both HAV and HBV, the combined HAV/HBV vaccine (given as 3 doses at 0, 1, and 6 months) can be used regardless of the patient’s immune status [Thompson, et al. 2021].

Hepatitis B Virus (HBV)

Discussion: The HBV vaccine is recommended for all adults with HIV who do not have immunity to HBV and who do not have chronic HBV infection [CDC 2023]. The antibody response to the HBV vaccine is reduced in individuals with HIV compared with those who do not have HIV; the reported immune response to the standard dose (20 µg) ranges from 34% to 89% [Mena, et al. 2015; Mast, et al. 2006], with diminishing response with lower CD4 cell counts [Pollack, et al. 2016; Pettit, et al. 2010; Kim, et al. 2008; Overton, et al. 2005]. Undetectable or very low viral load is associated with increased response to HBV vaccination [Mena, et al. 2015; Kim, et al. 2008; Overton, et al. 2005]. Initial vaccination should not be deferred in patients with low CD4 cell counts; some patients with HIV and CD4 counts ≤200 cells/mm³ may have an immune response [DHHS 2022; Whitaker, et al. 2012].

The 3 single-antigen HBV vaccines currently approved by the FDA for individuals ≥18 years old are Engerix-B, Recombivax HB, and Heplisav-B. PreHevbrio, a 3-antigen recombinant HBV vaccine, was approved in 2021 by the FDA for use for individuals ≥18 years old [FDA 2021], but experience regarding its use in patients with HIV is lacking at this time.

In 3 randomized controlled trials among individuals without HIV, administration of 2 doses of Heplisav-B was associated with a higher seroprotection rate than 3 doses of Engerix-B [FDA(b) 2020]. However, the 3 formulations have not yet been established to be equally effective in patients with HIV. A retrospective cohort study among individuals with HIV found seroprotection rates were increased with the Heplisav-B vaccine compared with other previously used HBV vaccines [Schnittman, et al. 2021]. In addition, a recent modeling study determined that use of Heplisav-B among individuals with HIV results in lower costs and increased benefits compared with Engerix-B [Rosenthal, et al. 2020]. The 2-dose option may facilitate completion rates for the vaccination series.

Improved immune response has been reported using a 4-injection double-dose (40 µg) regimen [Chaiklang, et al. 2013; Launay, et al. 2011]. Studies of a 3-injection double-dose regimen reported increased seroconversion rates compared with standard dose only among adults with HIV with CD4 counts >350 cells/mm³ and low or undetectable HIV viral load [Potsch, et al. 2012; Fonseca, et al. 2005]. Accelerated schedules (0, 1, and 3 weeks) may increase adherence to the full vaccination series but are not recommended for patients with CD4 counts ­≤500 cells/mm³ because of the increased likelihood of nonresponse [de Vries-Sluijs, et al. 2011]. Patients with HIV should be tested for anti-HBs 4 to 16 weeks after completing the vaccination series [DHHS 2022; Thompson, et al. 2021]. Other strategies to improve immune response have demonstrated some success, including intradermal administration [Launay, et al. 2011] and addition of adjuvants [Overton, et al. 2010; Cooper, et al. 2005; Sasaki, et al. 2003], but the evidence is not sufficient to make a recommendation.

Patients who do not respond to primary vaccination should be revaccinated with Heplisav-B or a double dose of the vaccine series previously administered. In a recent retrospective, cross-sectional study among individuals with HIV who failed to seroconvert after vaccination (anti-HBs negative and hepatitis B surface antigen negative) with Engerix-B or Recombivax HB, revaccination with Heplisav-B was highly effective in achieving seroprotection [Khaimova, et al. 2021]. If Heplisav-B is not administered as the initial HBV vaccination series, revaccination with the 2-dose series may be considered. Several studies have reported increased response rates from double-dose revaccination [Psevdos, et al. 2010; Cardell, et al. 2008; de Vries-Sluijs, et al. 2008], although the only randomized controlled trial comparing a 3-injection standard dose (20 µg) to a 3-injection, double-dose (40 µg) regimen for revaccination found no difference in response rates. However, the double-dose regimen resulted in a greater and more durable immune response [Rey, et al. 2015]. In patients who do not have an immune response to HBV vaccination and are initiating antiretroviral therapy, revaccination can be deferred until the CD4 count increases to ≥200 cells/mm³ [DHHS 2022]. Revaccination should not be delayed in patients who are unlikely to achieve an increased CD4 cell count.

For people who are susceptible to both HAV and HBV, the combined HAV/HBV vaccine can be used regardless of immune status, with 3 doses administered at 0, 1, and 6 months. Because no data are available regarding double-dose or 4-injection HBV vaccination with the combined HAV/HBV vaccine in individuals with HIV, the combined vaccine is not recommended for the double-dose or 4-injection HBV vaccination strategy.

Human Papillomavirus (HPV)

Discussion: In 2006, the U.S. Food and Drug Administration (FDA) approved a 9-valent vaccine that protects against nononcogenic HPV types 6 and 11 and oncogenic HPV types 16, 18, 31, 33, 45, 52, and 58 (Gardasil 9). Because it offers broader coverage of HPV types than other vaccines, the 9-valent vaccine is the only HPV vaccine available in the United States (see CDC: Supplemental information and guidance for vaccination providers regarding use of 9-valent HPV for more information). The HPV vaccine is approved by the FDA for preventive but not therapeutic use.

Extrapolating data from the demonstrated effectiveness of the quadrivalent HPV vaccine in older individuals [Wilkin, et al. 2018], the FDA expanded the age range for approved use of the HPV vaccine in the United States from ages 9 to 26 years to ages 9 to 45 years [FDA(a) 2020]. There is no specific mention of HIV infection in the updated FDA approval. Although 1 study demonstrated lower efficacy of the quadrivalent vaccine in individuals with HIV [Wilkin, et al. 2018], other research linked HIV viral suppression to vaccine efficacy [Money, et al. 2016].

When to vaccinate: HPV vaccination may be scheduled at the same time as standard adolescent vaccines offered at ages 9 to 12 years [CDC(a) 2021]. If possible, the HPV vaccine series should begin at 9 years old. The 3-dose vaccine is recommended for all patients with HIV who are 9 to 45 years old. The 9-valent HPV vaccine should be administered according to the CDC standard schedule for immunocompromised adults, children, and adolescents (a 3-dose regimen over a 6-month period at 0, 2, and 6 months) and should be offered regardless of CD4 cell count.

HPV vaccination provides high levels of neutralizing antibodies for at least 5 years and is protective in individuals ≤26 years old who do not have HIV, regardless of history of sexual activity; however, the full length of its protection has not been established. In an observational study conducted in England that examined the effectiveness of a national HPV immunization program, the reduction in cervical cancer was greatest in individuals who received the vaccine at ages 12 to 13 years [Falcaro, et al. 2021]. Although data are limited, the immunogenicity of the quadrivalent HPV vaccine has been demonstrated in individuals with HIV [Wilkin, et al. 2018; Kojic, et al. 2014].

Vaccination is not expected to change the course of established HPV infections but may prevent infection from other strains that are part of a polyvalent vaccine.

HPV testing and vaccination: HPV testing is not recommended before vaccine administration. It is unlikely that an individual will have been infected with all the HPV types covered by the 9-valent vaccine; therefore, it is expected that the 9-valent HPV vaccine will be effective against any of the 9 HPV types or any HPV types to which the individual has not been exposed. There also may be beneficial prevention due to cross-reactivity with other HPV types not included in the 9-valent vaccine [Wheeler, et al. 2012].

Revaccination with the 9-valent HPV vaccine is not currently recommended for individuals who previously received the bivalent or quadrivalent HPV vaccine [Petrosky, et al. 2015]. Vaccination with the quadrivalent HPV vaccine has demonstrated cross-protection against other oncogenic HPV types [Kemp, et al. 2011]. There is no maximum interval between vaccine doses as long as 3 doses are given, so there is no need to repeat doses if a scheduled vaccination is missed [CDC(a) 2021].

Influenza

Discussion: People with HIV are at greater risk of severe morbidity from an influenza infection [Grohskopf, et al. 2019; Kunisaki and Janoff 2009] than people who do not have HIV and should be vaccinated annually during flu season (October through May) according to standard CDC guidelines for all adults [Thompson, et al. 2021; Grohskopf, et al. 2019]. Inactivated influenza vaccine offers protective immunity in adults with HIV [Grohskopf, et al. 2019; Remschmidt, et al. 2014; Beck, et al. 2012]. Live, attenuated influenza vaccine should not be used for individuals with HIV. Antibody titers lower than those observed in the general population have been reported among adults with HIV, especially among those with advanced HIV disease who are ≥35 years old, have low CD4 cell counts, and have detectable viremia [Garg, et al. 2016; Crum-Cianflone(a), et al. 2011; Evison, et al. 2009; Yamanaka, et al. 2005; Kroon, et al. 2000]. Studies comparing intradermal and intramuscular vaccines report no difference in immunogenicity, but intradermal vaccination is associated with increased likelihood of redness, swelling, and tenderness at the injection site [Garg, et al. 2016; Seo, et al. 2016].

The CDC does not recommend a second vaccination in individuals with HIV [Grohskopf, et al. 2019], although one study reported that a second dose of an adjuvanted vaccine significantly increased the rate of seroprotective responses [Bickel, et al. 2011]. There is some evidence that influenza seroprotection is higher for people ≥18 years old who are given a double-dose vaccine than for those given the standard dose vaccine, but the clinical significance of this remains unknown [McKittrick, et al. 2013; Cooper, et al. 2011]. A study among children and young adults (3 to 21 years old) found no increased immunity among participants with HIV who received the double-dose vaccine [Hakim, et al. 2016].

Results of 2 studies suggest a possible benefit to delaying influenza vaccination to after mid-November; patients vaccinated later in the flu season had lower rates of laboratory-confirmed influenza and influenza-like illnesses than those vaccinated earlier in the season [Glinka, et al. 2016; Werker, et al. 2014]. Monitoring regional influenza activity will help ensure appropriate timing of influenza vaccination. There is no recommendation for post-vaccination serologic testing to determine immune response [Grohskopf, et al. 2019].

Measles, Mumps, Rubella (MMR)

Discussion: Immunocompromised individuals are at increased risk of serious and life-threatening complications if infected with measles [McLean, et al. 2013]. Patients with HIV who have CD4 counts ≥200 cells/mm³ for ≥6 months and who do not have evidence of immunity to MMR should be vaccinated with 2 doses of MMR vaccine ≥4 weeks apart. Documentation of previous age-appropriate vaccination or laboratory confirmation of prior disease is acceptable evidence of immunity. Serologic screening is required if other acceptable evidence of immunity is not available and to determine rubella immunity among individuals of childbearing potential. In the absence of other evidence of immunity, individuals with perinatally acquired HIV who received childhood vaccination with MMR before establishment of effective antiretroviral therapy (ART) should be revaccinated (2 doses) after effective ART is established [McLean, et al. 2013]. There is no recommendation for post-vaccination serologic testing to determine immune response [McLean, et al. 2013].

Two studies that examined the antibody response after MMR vaccination in adults with HIV taking ART reported high levels of protective antibodies post-vaccination, although the levels were lower than in adults without HIV. A study conducted in Mexico among adults with HIV who were seronegative for measles reported no significant difference in initial antibody response to measles vaccination between adults with and without HIV (81% vs. 85%). However, at 1 year, the observed decline in antibody response was faster in adults with HIV than in those without HIV [Belaunzaran-Zamudio, et al. 2009]. A study in Thailand reported protective antibodies to measles (74.1%), mumps (65.7%), and rubella (93.3%) among adults with HIV 8 to 12 weeks after MMR vaccination. Compared with adults without HIV, the seroconversion rates were lower but reached statistical significance only for mumps [Chaiwarith, et al. 2016].

No data are available on revaccination in adults with HIV. Revaccination has improved measles antibody response in children with HIV on ART who had an inadequate initial response to vaccination [Abzug, et al. 2012; Aurpibul, et al. 2007]. If individuals previously vaccinated with 2 doses of a mumps-containing vaccine are identified as having increased risk for mumps by public health authorities because of an outbreak, these at-risk individuals should receive a third dose of a mumps-containing vaccine to improve protection against mumps disease and related complications [Marin, et al. 2018].

MMR vaccination contains live virus and is contraindicated for patients with CD4 counts <200 cells/mm³ because of reports of adverse events, such as measles pneumonitis, in severely immunocompromised patients [Angel, et al. 1998; CDC 1996]. Serious adverse effects have not been reported in adults who were not severely immunocompromised [Chaiwarith, et al. 2016; McLean, et al. 2013; Belaunzaran-Zamudio, et al. 2009]. The MMR + varicella vaccine has not been adequately studied in individuals with HIV and is not recommended as a substitute for the MMR vaccine in this population [McLean, et al. 2013].

Meningococcal Serotypes A, C, W, and Y (MenACWY)

Discussion: Adults with HIV are at increased risk of invasive meningococcal disease due to serogroups C, W, and Y [Mbaeyi, et al. 2020; Folaranmi, et al. 2017]. A study in New York City reported a 10-fold increased risk of invasive meningococcal disease in patients with HIV, with the highest risk among those with CD4 counts ≤200 cells/mm³ [Miller, et al. 2014]. As of 2020, the CDC recommends vaccinating all previously unvaccinated adults with HIV with a 2-dose primary series of MenACWY vaccine (MenACWY-CRM, MenACWY-D, or MenACWY-TT) administered ≥8 weeks apart [Mbaeyi, et al. 2020].

Data on meningococcal vaccine efficacy among adults with HIV are not currently available [Mbaeyi, et al. 2020]. Among adolescents with HIV, available evidence indicates that the vaccine is immunogenic and serious adverse events are rare, but adolescents with HIV (and especially those with lower CD4 cell counts and higher viral loads) had reduced antibody levels compared with adolescents without HIV [Lujan-Zilbermann, et al. 2012; Siberry, et al. 2010]. Adding a second vaccine dose significantly improved antibody levels 28 and 72 weeks after immunization, particularly among adolescents with CD4% ≥15 [Lujan-Zilbermann, et al. 2012].

Booster doses every 5 years are needed to maintain immunity. There is no recommendation for post-vaccination serologic testing to determine immune response [Mbaeyi, et al. 2020].

Meningococcal Serotype B (MenB)

Discussion: The MenB vaccine offers protection against MenB infection. MenB vaccine is not routinely recommended for adults with HIV unless they have another indication for immunization. No increased risk of serogroup B meningococcal disease among individuals with HIV has been reported [CDC 2023].

Mpox

Immunization: The CDC considers people with HIV to be at risk for severe mpox disease and recommends prioritization of those at risk for receipt of the JYNNEOS mpox vaccine [CDC(b) 2022]. Vaccination is used to prevent mpox and as post-exposure prophylaxis; it protects against disease when administered before exposure. If administered after exposure, the vaccine may prevent development or decrease the severity of mpox disease (see CDC: Interim Clinical Considerations for Use of JYNNEOS and ACAM2000 Vaccines During the 2022 U.S. Monkeypox Outbreak).

Two vaccines against mpox are currently approved by the U.S. Food and Drug Administration: JYNNEOS (Imvamune or Imvanex) and ACAM2000. Only JYNNEOS is safe for people with HIV. The ACAM2000 vaccine is contraindicated in adults with HIV and their household contacts.

JYNNEOS contains live vaccinia virus, but the virus does not replicate in humans. JYNNEOS is considered safe to use in adults with HIV regardless of viral load or CD4 cell count. No data are available on the effectiveness of available mpox vaccines in this current outbreak, but a fulminant form of mpox has been reported in people with advanced immunosuppression due to HIV [Mitja, et al. 2023].

The safety and immunogenicity of the JYNNEOS vaccine have been evaluated in adults with HIV; however, the immunogenicity is unknown in individuals who are not virally suppressed or who have with CD4 counts ≤200 cells/mm³. Vaccine efficacy may be lower in patients with low CD4 cell counts. However, given the risk of severe illness in immunosuppressed individuals, vaccination is recommended regardless of CD4 cell count and degree of viral suppression.

Vaccine dosing: The CDC recommends the mpox vaccine be given within 4 days of exposure to prevent disease. If given 4 to 14 days after exposure, vaccination may not prevent disease but may reduce symptoms [CDC(b) 2022]. Peak immunogenicity is achieved 2 weeks after the second JYNNEOS dose [Rao, et al. 2022].

Presentation: A high index of suspicion is required because the clinical presentation of mpox disease can vary from a few scattered papules and mild constitutional symptoms to severe illness. Symptoms of mpox may include fever, headache, muscle aches, backache, swollen lymph nodes, moderate to severe pain, exhaustion, and rash that may include painful oral, anal, or genital lesions.

Mortality: Studies of mpox in remote, medically underserved areas of Central Africa have reported mortality of 11% in unvaccinated individuals [Durski, et al. 2018]. People with advanced HIV or who are not virally suppressed may be at risk of severe disease. To date, no deaths have been reported in the United States during the current outbreak, but a fulminant form of mpox has been reported in people with advanced immunosuppression due to HIV [Mitja, et al. 2023].

Transmission: Although many of those affected in the current global outbreaks are men who have sex with men, the virus can be acquired by anyone who has been in close contact with someone with mpox. The virus that causes mpox is transmitted via the following:

• Direct skin-to-skin contact with an infectious rash, scabs, or body fluids
• Exposure to respiratory secretions during prolonged face-to-face contact or intimate physical contact, such as kissing, cuddling, or sex
• Touching objects or fabrics (e.g., clothing or linens) that have been in contact with the rash or body fluids of someone with mpox
• Being scratched or bitten by an infected animal

Pneumococcal

Discussion: Individuals with HIV are at increased risk of serious disease due to Streptococcus pneumoniae, including bacteremia, meningitis, and pneumonia. Pneumococcal vaccination is recommended for all adults with HIV as soon as possible after HIV diagnosis [CDC 2023; Kobayashi, et al. 2022]. Patients who have not previously been vaccinated or whose vaccination status is unknown should receive 1 dose of PCV15 or 1 dose of PCV20; if PCV15 is used, it should be followed with 1 dose of PPSV23, with a minimum interval of 8 weeks between the doses. There is no recommendation for post-vaccination serologic testing to determine immune response [CDC 2023; Kobayashi, et al. 2022]. See the CDC: PneumoRecs VaxAdvisor for vaccination recommendations by age and pneumococcal immunization history.

Pneumococcal vaccination has been shown to reduce pneumococcal bacteremia and mortality among adults with HIV [Chowers, et al. 2017; Rodriguez-Barradas, et al. 2008; Grau, et al. 2005; Hung, et al. 2004]. Both polysaccharide and conjugate pneumococcal vaccines appear to be safe and immunogenic among adults with HIV who have CD4 counts ≥200 cells/mm³ [Lombardi, et al. 2016; Bhorat, et al. 2015; Rodriguez-Barradas, et al. 2015; Ho, et al. 2013].

Patients with CD4 counts <200 cells/mm³ are at the highest risk of pneumococcal disease. Immunogenicity was demonstrated for individuals with HIV with CD4 counts <200 cells/mm³ who received PCV7 [French, et al. 2010]. Patients with HIV who have not previously received any pneumococcal vaccine should receive a dose of PCV15 or PCV20, regardless of CD4 cell count. Although there is evidence of the effectiveness of PPSV23 among patients with CD4 counts <200 cells/mm³, the benefit appears to be greatest among patients with HIV RNA levels <100,000 copies/mL and among those who are on antiretroviral therapy [French, et al. 2010].

Contraindications to pneumococcal vaccination include a history of anaphylaxis caused by any vaccine component. Patients with a history of an anaphylactic reaction to any conjugate vaccines or diphtheria toxoid should not receive conjugate vaccine [CDC 2023].

Tetanus, Diphtheria, and Pertussis (Tdap) and Tetanus-Diphtheria (Td)

Discussion: The recommendations for Tdap and Td vaccination of adults with HIV are the same as for those in the general population [CDC 2023; Thompson, et al. 2021]. The safety and efficacy of vaccination with Tdap has not been studied in this population [Crum-Cianflone and Wallace 2014].

Varicella

Discussion: Patients with HIV who have CD4 counts ≥200 cells/mm³ and do not have immunity to varicella should be vaccinated according to CDC guidelines for all adults, with 2 doses of single-antigen varicella vaccine administered 4 to 8 weeks apart or a second dose if they have received only 1 dose. Varicella vaccination contains live virus and is contraindicated for patients with CD4 counts <200 cells/mm³ because of the risk of disseminated disease [CDC 2023; Marin, et al. 2007; Kramer, et al. 2001]. Data on the effectiveness of varicella vaccination among adults with HIV are lacking, but vaccination has been shown to be effective among children with HIV [Crum-Cianflone and Wallace 2014; CDC 2012; Marin, et al. 2007].

Because of the possibility of severe disease in individuals with HIV, clinicians should verify varicella immunity. Birth before 1980 is not accepted as evidence of immunity in immunocompromised individuals; anti-varicella immunoglobulin G screening should be performed in patients with HIV who have no known history of chickenpox or shingles [Marin, et al. 2007]. Post-vaccination serologic testing to determine immune response is not recommended because commercially available assays lack sensitivity and may give false-negative results [Marin, et al. 2007]. Clinical disease due to varicella after vaccination, a very rare event, should be treated with acyclovir [DHHS 2022; Marin, et al. 2007]. If household members or close contacts develop a rash after vaccination, people with HIV should avoid contact with the affected individual until after the rash resolves [ACIP 2022; Marin, et al. 2007]. Because they can interfere with vaccine virus replication and decrease vaccine effectiveness, all antiherpetic agents should be avoided for at least 24 hours before varicella vaccination through 14 days after [ACIP 2022; CDC(b) 2021]. If post-exposure varicella zoster immune globulin is given, clinicians should wait ≥5 months before varicella vaccination [ACIP 2022; DHHS 2022; CDC 2006].

Zoster

Discussion: People with HIV are at increased risk of zoster (initial episodes and recurrences) at all stages of HIV disease; the risk is greater among those with severe immunodeficiency and lower CD4 cell counts [Blank, et al. 2012; Harpaz, et al. 2008]. Zoster vaccination may reduce disease burden in individuals with HIV; however, data on the use of zoster vaccine among adults with HIV are limited.

The Advisory Committee on Immunization Practices recommends 2 doses of recombinant zoster vaccine (RZV; brand name Shingrix) to prevent herpes zoster in adults ≥19 years old who are immunosuppressed [Anderson, et al. 2022]; the previous recommendation was for vaccination of adults ≥50 years old [Dooling, et al. 2018]. On December 1, 2021, the MCCC updated its recommendation as well: Adults with HIV ≥18 years old should receive 2 doses of RZV, administered 2 to 6 months apart. RZV provides strong protection against shingles and post-herpetic neuralgia. There is no specific data on immunogenicity in people with HIV; however, superior efficacy and longer duration of seroprotection have been demonstrated in the elderly [Anderson, et al. 2022; Dooling, et al. 2018]. As of November 2020, the live, attenuated zoster vaccine (ZVL; brand name Zostavax) is no longer available for use in the United States.

Anti-varicella IgG screening should be performed in patients with no known history of chickenpox or shingles [Marin, et al. 2007], and patients with a negative titer should be vaccinated for varicella if their CD4 count is >200 cells/mm³ as an initial step, and the series should be completed before zoster vaccination. There is no recommendation for post-vaccination serologic testing to determine immune response [Harpaz, et al. 2008].

All Recommendations

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Supplementary Material

Supplement: Guideline Development and Recommendation Ratings