BritishHIVAssociationguidelinesontheuseofvaccinesinHIV-positiveadults:summaryofrecommendations

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Infection/disease Vaccine Replicating Primarycourse Indication NotesVaccineswithbroadindicationsHepatitisA Inactivated No 2or3doses Non-immune,atrisk 3dosesifCD4count<350cells/μLHepatitisB Subunit No 4doses Allnon-immune Dose:EngerixB2x20µg;HBvaxPRO40µg;Fendrix20µgHumanpapillomavirus VLP No 3doses Ageandgenderrelated 4vHPVor9vHPVpreferred;seeBHIVAguidanceInfluenza Inactivated No 1dose All,yearly QuadrivalentvaccinepreferredMeningococcus Conjugated No 2doses Agerelated,atrisk MenACWY;combinedasHib/MenC;follownationalguidanceMeningococcus Recombinantprotein+OMV No 2doses Agerelated,atrisk MenB;follownationalguidancePneumococcus Conjugated No 1dose All,once PCV-13Pneumococcus Polysaccharide No 1dose Atrisk,once PPV-23;follownationalguidancePertussis Acellularmulticomponent No 1dose Pregnantwomen CombinedasdTaP/IPV;follownationalguidanceMeasles,mumps,rubella Liveattenuated Yes 2doses Allnon-immune CombinedasMMR;CD4count>200cells/µLVaricella(chickenpox) Liveattenuated Yes 2doses Allnon-immune CD4count>200cells/µLHerpeszoster(shingles) Liveattenuated Yes 1dose Agerelated CD4count>200cells/µL;VZVIgG+;follownationalguidanceVaccineswithpredominantlytravel-relatedindicationsCholera Inactivated+subunit No 2doses Selectiveuse WC/rBs;oraladministrationJapaneseencephalitis Verocell-derivedinactivated No 2doses Tick-borneencephalitis Inactivated No 3–4doses Tetanus Toxoid No 1dose CombinedasTd/IPVvaccineDiphtheria Toxoid No 1dose CombinedasTd/IPVvaccinePoliovirus Inactivated No 1dose CombinedasTd/IPVvaccineRabies Cell-culturederived No 3doses 5dosesforpost-exposureprophylaxisTyphoid Polysaccharide No 1dose ViCPS;parenteralYellowFever Liveattenuated Yes 1dose <60yearsonly;CD4count>200cells/μLVaccineswithselectedindicationsAnthrax Filtrateofbacterialproteins No 4doses Occupational AVPHaemophilusinfluenzaeB Conjugated No 1dose Atrisk CombinedasHib/MenCNotpreferredandcontraindicatedvaccinesHepatitisA/Bcombined No Notpreferred ReducedimmunogenicityHepatitisA/typhoidcombined No Notpreferred ReducedHAVimmunogenicityInfluenza Liveattenuated Yes Notpreferred IntranasalTuberculosis BCG Yes Contraindicated Typhoid Liveattenuated Yes Contraindicated OraladministrationVLP:virus-likeparticle;OVM:outermembranevesicles;Hib:HaemophilusinfluenzaeB;Td/IPV:tetanus/diphtheria/inactivatedpoliovirus;dTaP/IPV:diphtheria/tetanus/acellularpertussis/inactivatedpoliovirus;VZV:varicellazostervirus;AVP:anthraxvaccineprecipitated;ViCPS:Vicapsularpolysaccharidevaccine

BritishHIVAssociationguidelinesontheuseofvaccinesinHIV-positiveadults:summaryofrecommendations

Endorsedby:

Notes:

• In2015,BHIVA(BritishHIVAssociation)issuedguidelinesontheuseofvaccinesinHIV-positiveadults[1].TheguidelinesweregradedtoindicatethestrengthoftherecommendationandthequalityofthesupportingevidenceusingtheGRADEsystem[2],anddevelopmentfollowedthestandardssetbyNICE(NationalInstituteforHealthandCareExcellence).

• Protectionagainstvaccine-preventableinfectionsisimportanttoensureHIV-positivepeopleenjoylongandhealthylives.ThesuccessofantiretroviraltherapymeansthatHIV-positivepeopleenjoymuchimprovedimmunefunctionandlifespan,andareincreasinglylikelytoengageinactivities,travel,oroccupationsthatcarryariskofexposuretoinfectiousagents.Theseindividualsshouldnotbedeniedprotectionifevidenceindicatesvaccinationissafeandimmunogenic.

• ResponsestovaccinationareoftensuboptimalinuntreatedHIV-positivepatients.Whileresponsesimprovewithantiretroviraltherapy,theymayremainloweranddeclinemorerapidlythaninHIV-negativeindividuals.However,itisoftenpossibletoimprovevaccineimmunogenicitybyofferingmodifiedvaccineschedules,withhigherormorefrequentdoses,withoutcompromisingsafety.ThisapproachisreflectedintheBHIVAguidelines.

• InApril2016,theMHRA(Medicines&HealthcareProductsRegulatoryAgency)highlightedtheimportanceofavoidinglive(replicating)vaccinesinpeoplewhoareimmunocompromised [3]. It is often perfectly safe to use replicating vaccines in HIV-positive patients, as they are not necessarily immunocompromised. BHIVAprovidesevidence-basedguidanceonthesafeuseofreplicatingvaccinesinthispatientgroup.Specifically:o HIV-positiveadultswithCD4cell countsbelow200cells/μLmustnotbegiven replicatingvaccinesdue toapotential riskofvaccine-associateddisease;when

indicated,vaccinationshouldbepostponeduntiltheCD4cellcounthasimprovedonantiretroviraltherapy.o HIV-positiveadultswithaCD4cellcountof200–350cells/μLhavemoderateimmunodeficiency.Clinicaljudgementshouldguidetheuseofreplicatingvaccinesin

thesepatients.Whereexposureislikely,naturalinfectionoftencarriesagreaterriskofadverseoutcomesthanvaccination(e.g.measles,chickenpox),makingtheofferofvaccinationthepreferredoption.Antiretroviraltherapyimprovesthesafetyandimmunogenicityofvaccinationinthisgroup.

o WiththeexceptionoftheMMR(measles,mumps,rubella)vaccine,co-administrationofmultiplereplicatingvaccinesisnotrecommendedduetouncertaintiesoversafetyandefficacy.Anintervalofatleast4weeksbetweenvaccinationsisrecommended.

o Regardless of the CD4 cell count, contraindications to the use of replicating vaccines that apply to the general population (e.g. in relation to the use ofimmunosuppressivetherapy)alsoapplytoHIV-positivepatients.PleaserefertotheGreenBookfordetails[4].

o Case-specificguidancereflectiveofindividualcircumstancesshouldbesoughtfromtheresponsibleHIVclinician.References1. www.bhiva.org/vaccination-guidelines.aspx2. www.gradeworkinggroup.org/3. www.gov.uk/drug-safety-update/live-attenuated-vaccines-avoid-use-in-those-who-are-clinically-immunosuppressed4. www.gov.uk/government/collections/immunisation-against-infectious-disease-the-green-book

PleasedirectenquiriestoProfAnnaMariaGeretti:geretti@liverpool.ac.ukorbhiva@bhiva.org