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MKSAP 19 "Quiz Me!" Question: Answer and Critique

Answer

E: No contraindications exist

Educational Objective

Identify appropriate vaccines for patients with HIV infection.

Critique

This patient has no contraindications to routinely administered vaccines (Option E). Live vaccines, including varicella, varicella-zoster, measles-mumps-rubella, and influenza are not recommended for patients who are severely immunocompromised. Contraindications to live vaccines include persons with HIV with CD4 cell count ≤200/µL; pregnancy or probable pregnancy within 4 weeks; immunosuppressant therapy, including high-dose glucocorticoids; leukemia, lymphoma, or other bone marrow and lymphatic system malignancies; cellular immunodeficiency; solid organ transplant recipient; and recent hematopoietic stem cell transplantation.

The live-attenuated influenza vaccine is contraindicated in patients with HIV infection regardless of CD4 cell count, but the inactivated vaccine can be given (Option B). Numerous other immunizations are recommended for all persons with HIV, including COVID-19, 13-valent pneumococcal conjugate, and 23-valent pneumococcal polysaccharide vaccines. Patients who are not already immune or infected with hepatitis B virus should receive the hepatitis B vaccine series. Tetanus-diphtheria-pertussis, hepatitis A, and human papillomavirus (HPV) vaccinations are indicated as for the general population (Option A). The Advisory Committee on Immunization Practices (ACIP) has expanded the age indications for HPV vaccination to 45 years, recommending that the decision to vaccinate between ages 26 and 45 years be determined through shared decision making with patients. The ACIP recommends that all persons with HIV infection be vaccinated for meningococcal disease with the quadrivalent meningococcal vaccine, including boosters every 5 years.

For prevention of varicella-zoster, live-attenuated and recombinant vaccines are available; the inactivated recombinant vaccine is preferred and recommended for patients aged 50 years and older, even if the patient previously received the live varicella-zoster vaccine. For patients without immunity, selected live vaccines such as the measles-mumps-rubella and varicella vaccines can be given to patients with HIV infection as long as the CD4 cell count is greater than 200/µL (Option C, D).

Key Points

  • Selected live vaccines, including the varicella and measles-mumps-rubella vaccines, are safe to administer to nonimmune persons with HIV infection whose CD4 cell count has consistently been greater than 200/µL.
  • The live influenza vaccine is contraindicated in immunocompromised patients and those with HIV regardless of CD4 cell count.

Bibliogrpahy

Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. Updated April 17, 2020. Available at https://aidsinfo.nih.gov/guidelines/html/4/adult-and-adolescent-opportunistic-infection/0.

Back to the March 2022 issue of ACP IMpact