HIV Clinician, Summer 2008, Vol. 20, No.

3, pages 1, 4-6
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Which immunizations are safe for HIV patients?

Sheryl Thornton, DNS, RN

T
his article comes as the result of a phone call regarding immunizations and HIV. The caller was
interested in knowing which vaccines were safe for HIV patients. Immunizations have been a source of
confusion among clinicians, particularly those responsible for the care of HIV-infected patients.
Questions remain regarding which vaccines are safe and which vaccines are contraindicated in certain
circumstances. What are the compositions of these vaccines that result in these contraindications? But a
more challenging question relates to efficacy. Are these vaccines actually providing immunity to the HIV-
infected recipient?
When a child first registers for school, evidence must be presented that he/she is “up-to-date” on
immunizations. This is a complete series of vaccinations required by respective states for school entry.17
However, some parents and other adults refer to these vaccines as “baby shots,” thereby implying that no
further immunizations are needed in the late teen or adult years. For adults, the routine health care
examination and screening, with evidence of proper and up-to-date immunizations, are roles assumed by the
health care provider. For adults who are immunocompromised due to HIV disease or certain cancers,
immunizations may provide a safety measure to prevent complications. While some immunizations provide a
lifetime of immunity, others require “booster” doses to maintain their ongoing immunity, or some require
annual revision based on current formulations.
Immunization schedules are published annually through the recommendations of the CDC, ACIP (Advisory
Committee on Immunization Practices), and respective state health departments. In Louisiana, for example,
the Immunization Schedule is distributed annually by the Department of Health and Hospitals.12 This
schedule is available to health care providers, clinics and hospitals and provides vaccine administration
tables and regulations for children between the ages of birth and 12 years, including accelerated schedules for
children who started immunizations late. Similarly, a schedule is published for pediatric age groups aged 0-6
and 7-14 through the CDC.5 The Recommended Adult Immunization Schedule is published annually by the
CDC, giving guidelines and restrictions regarding immunizations to three age groups: 19-49, 50-64, and > 65
years.4
So how does this translate to individuals who are affected by HIV? In the adult guidelines, specific
information is provided regarding the safety of administration of most vaccines, however these guidelines are
not provided in the state immunization schedule for the pediatric HIV+ patient. A brief review of vaccine
composition may reveal which vaccines may or may not be administered to the HIV+ patient.
Vaccines are usually composed of the actual virus or bacteria, or some portion thereof. Different terms are
used to indicate the composition of the vaccine, such as live, attenuated, inactivated; and toxoid or
polysaccharide indicating use of part of the bacteria, or virus. For example, a vaccine may be labeled “live,
attenuated” meaning that the virus is live, but has been altered or changed in some way, usually weakened,
so that the virus does not have its full virulent ability.7,23 Two vaccines that use this composition are the MMR
(measles, mumps, and rubella vaccine) and the varicella vaccine. One major advantage to this type of vaccine
is that one or two doses is sufficient to provide a lifetime of immunity because they elicit strong antibody
responses within the body. A major disadvantage is that it cannot be administered to some groups who are
immunocompromised or to patients with certain forms of cancer. Most live virus vaccines must be refrigerated
to maintain potency, and may be contraindicated in patients who are HIV infected.
Another form of vaccine is the inactivated (killed) virus. This vaccine uses the virus that has been killed,
yet the body is able to form protection against this virus. Some examples of this type of vaccine include the
inactivated polio vaccine, the hepatitis A vaccine, and the trivalent inactivated influenza vaccine. One of the
primary advantages is that it cannot cause a mild form of the disease because the virus is dead, therefore it
can be used safely in HIV+ recipients. Because the virus is killed, several doses may be required to achieve
immunity. Using part of the virus is another method used in making vaccines, sometimes referred to as
“subunit vaccines.” It has been found to be effective in eliciting an immune response that is sufficient for
protection. By using part of the virus, the chances of adverse reactions to the vaccine are lower, and these
may be used in HIV+ patients. The hepatitis B vaccine is one example; though this type of vaccine may
provide a lifetime of immunity, it does require administration of more than one dose. Finally, another form of
vaccine composition is using part of bacteria, such as in toxoid vaccines after deactivation, or in conjugate
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vaccines, which are the polysaccharide outer coating of the organism. The diphtheria, tetanus, pertussis,
conjugated polysaccharide-Hemophilus influenzae B (HiB), pneumococcal, and meningococcal vaccines are
examples.7
Of the 12 most commonly administered vaccines for use in the United States, three present some
precautionary suggestions and should be administered based on CD4 or CD4% levels: MMR, varicella, and
zoster.4,19 Other vaccines may be administered without regard to the patient’s CD4. The first vaccine in this
group is the tetanus-diphtheria-pertussis vaccine. There are at least four different formulations for this
vaccine: 1) The DTaP which uses acellular pertussis therefore is less reactogenic. This form of the vaccine is
commonly used during the initial series of the vaccine. 2) The DPT, not used since 2002. 3) The Tdap,
composed of tetanus toxoid, reduced diphtheria, and acellular pertussis vaccine, now recommended for
adults 19-64 to replace the next booster dose of the tetanus and diphtheria toxoid. 4) The Td vaccine which
must be repeated every ten years. These groups of vaccines are not contraindicated in HIV+ patients.3,4,18
Though rarely used in the world today, the OPV or oral polio vaccine is a live virus that literally wiped out
polio in the Western Hemisphere; however, its use is contraindicated in the HIV-infected patient. The IPV, or
inactivated (killed) polio vaccine, which is in an injectable form, does not use a live virus, and may be safely
used in HIV-infected patients (22).
The Haemophilus influenzae type b or HiB is commonly given to young children between the ages of 6
weeks to 70 months. This vaccine has no apparent effect on older children and adults, and may safely be
used in HIV-infected children. Another vaccine targeted for young children is the rotavirus vaccine. Rotavirus
is commonly seen in children under the age of 5, is considered highly contagious, and is spread by oral-fecal
contact. Administered in three oral doses at ages 2, 4, and 6 months, recommendations for use of this vaccine
among HIV-infected children must be assessed on a case-by-case basis, determining the potential benefits
against the risks.21
The HPV vaccine is routinely given to girls 11 and 12 years of age, and is recommended for all females ages
13-26. This 3-dose vaccine is recommended to be administered before the onset of sexual activity. It is
recommended that the interval between the first and second dose be eight weeks, and the third dose should
be administered six months after the first dose. This vaccine offers no contraindications for women who are
HIV infected, have a history of genital warts, or a history of an abnormal pap smear. The incidence of
squamous intraepithelial lesions of any grade and the risk for invasive cervical cancer are more prevalent in
HIV-infected women, yet another reason for recommending the HPV vaccine.8
The conjugate pneumococcal vaccine is used in children <2 years of age given at 2, 4, 6, and 12-15 months
of age. The polysaccharide vaccine is used in those over the age of 2 years and is also used in patients with
chronic medical conditions, including HIV. One note regarding this vaccine: Adults below the age of 65 may
require re-vaccination and it is suggested that vaccination should occur as close to the initial diagnosis of HIV
as possible.1
Hepatitis A and B vaccines are both recommended for use in the HIV-infected patient. Hepatitis A vaccine
is also recommended for patients with chronic liver disease, those receiving clotting factors, IVDUs, MSMs,
children, and travelers to endemic regions. The vaccine is given in two doses six months apart, It is
recommended that an HAV screen be performed before administering vaccine.9 Hepatitis B is administered to
all infants and children born after November 21, 1991, especially to mothers who are HBsAg+. It is further
recommended for health care workers, morticians, those requiring frequent transfusions, HIV+ and hepatitis
C+ patients, those patients who are recently starting hemodialysis, IVDUs, high risk sexual practitioners,
household contacts of those with active hepatitis B, and populations where hepatitis B is endemic.
Hepatitis B vaccine can be administered in two forms, according to the ACIP Recommendations for HIV-
infected adults. Engerix-B is administered in 20 ug/ml x 2 (40 ug total) on a 4-dose schedule of 0, 1, 2 and 6
months, or Recombivax-HB 40 ug/ml x 1 on a 3-dose schedule of 0, 1 and 6 months.1,19
The meningococcal vaccines are scheduled to be administered to children ages 11 and 12 who are on
“track” with their immunization schedule. Other groups targeted for administration include first year college
students living in dorms, military recruits, and asplenic patients. According to ACIP, administer MCV4 at age
11-12 and at age 13-18 years if not previously vaccinated, with MPSV4 being an acceptable alternative.1,5 This
vaccine may be safely used in the HIV-infected patient.
The influenza vaccine, according to the 2007 ACIP Recommendations, should be administered annually to
HIV-infected patients, with the trivalent inactivated vaccine. Two forms of the vaccine exist, the trivalent
inactivated vaccine (TIV) and the live, attenuated, trivalent vaccine (LAIV). The latter (LAIV) is contraindicated
in patients with HIV. Vaccinations in HIV-infected patients should occur between October and December and
regardless of CD4 cell count.1,4,18,19
The three vaccines with precautionary warnings for HIV-infected patients are MMR, varicella, and zoster.

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The MMR is composed of live virus and is contraindicated in children who are immunosuppressed by diseases
such as cancer or HIV infection with a CD4% count below 15. It is contraindicated in HIV-infected adults with
CD4 counts < 200 and it may not be administered to pregnant women or those planning a pregnancy within
four weeks of receiving the vaccine. The varicella vaccine should not be administered to HIV-infected clients
with CD4 < 200 or CD4 percent < 15% and it is not required in those with a history of varicella based on
diagnosis. It too, is contraindicated in women who are pregnant or may become pregnant within four weeks of
receiving the vaccine. Lastly, the zoster vaccine is used in the prevention of “shingles” and is contraindicated
in HIV-infected patients, those on steroid therapy, patients with active and/or untreated tuberculosis,
individuals who are pregnant or planning a pregnancy, and those with life-threatening allergies to gelatin or
neomycin. Those patients who may be contemplating international travel may want to check with their HIV
specialist to determine other international vaccines required prior to leaving the United States that may be
contraindicated in the HIV-infected patient (yellow fever, typhoid Ty21a).16,19
The questions remain whether administration of immunizations will have the desired effect and whether
there are efficacy reports indicating that vaccines do indeed help in combating the disease for which they were
developed to prevent. In a review of the literature on the use of immunizations, these reports examined
immunization use in adults and children, the formation of antibodies, and viral load responses as a measure
of reaction. Melvin and Mohan (2003) examined subject response in children on HAART and the formation of
antibodies for HiB, tetanus, and measles vaccines. Their findings indicated that in most of the subjects,
antibody levels remained detectable one year after immunization if being treated with HAART.14
Tasker et al (1999) examined the effects of the influenza vaccine in HIV-infected adults. Their findings
indicated that those who received the vaccine had far fewer reports of respiratory illness and no lab-confirmed
diagnoses of influenza. Further, they reported no change in HIV RNA or CD4 cell count among vaccine
recipients.21 Anema et al. (2008) examined the efficacy of the influenza vaccine via meta-analysis, and
concluded that there was insufficient evidence supporting effectiveness of the vaccine based on poorly
quantified data and methodological shortcomings in the studies reviewed.2
A study in the New England Journal of Medicine (Klug, et al, 2003) examined the effects of the conjugate
pneumococcal vaccine in both HIV+ and HIV- children, finding that both groups benefitted by an overall
decrease in the incidence of pneumonia and invasive pneumococcal disease.11 However, a study from Uganda
(2000) indicated that HIV+ patients actually had a higher incidence of pneumonia post vaccination.10 A later
study (2003) examined the safety and efficacy of the pneumococcal vaccine in infants and children at a
pediatric AIDS Clinical Trials Group Study. Findings by Nachman et al indicated that the pneumococcal
vaccine was safe and immunogenic for preventing invasive pneumococcal disease in HIV+ infants and
children.15
Despite these and other findings, the final decisions regarding immunizations are based on the clinical
judgment of the care provider and the CDC recommendations which include the following:
-Most vaccines can safely be administered to children and adults who are HIV infected.
-Many preventive vaccines are encouraged in HIV-infected patients, for example, influenza, pneumococcal,
hepatitis A and B.
-The recipients should be assessed to determine if initial vaccines were given during childhood, via history,
titer reports, etc.
-The CD4 count must be above certain levels prior to administration of certain live viruses.
-Absolute contraindications can exist when the CD4 counts are below 200 or the CD4 percent is less than
15%.

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REFERENCES
Advisory Committee on Immunization Practices (2007) Recommended Adult Immunization Schedule: United States, October 2007-September
2008. Annals of Internal Medicine, 147, 10, 725-129.
Anema, A., Montaner, J., Brownstein, J., & Cooper, C. (2008) Efficacy of influenza vaccination in HIV-positive Patients: A Systematic Review and

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Meta-Analysis. HIV Medicine, 9, (1), 57-61.
Broder, K., Cortese, M, Idkander, J., et al (2006). Preventing Tetanus, Diphtheria, and Pertussis among Adolescents: Use of Tetanus Toxoid,
Reduced Diphtheria Toxoid and Acellular Pertussis Vaccines. MMWR, 55, (RR03: 1-34.
CDC (2007) Recommendations and Guidelines: Adult Immunization Schedule. www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm
CDC (2007) Recommendations and Guidelines: 2008 Child & Adolescent Immunization Schedules. www.cdc.gov/vaccines/rec/schedules/child-
schedule.htm
CDC (2007). Vaccines & Immunizations: Who Should Not Get Vaccinated with these Vaccines. www.cdc.gov/vaccines/vpd/should-not-vacc.htm
12
Children’s Hospital of Philadelphia (2007). Vaccine Education Center: How Are Vaccines Made? www.chop.edu/consumer/jsp/division/generic
DeVuyst, H & Franceschi, S. (2007) Human papillomavirus vaccines in HIV-positive Men and Women. Current Opinion in Oncology, 19, (5) 470-475
Flower, S. (2003) Performing Initial Assessment of the HIV-Positive Patient. Physician Assistant, 27, 8, 25-37.
French, et al (2000) 23-Valent Pneumococcal polysaccharide vaccine in HIV-1 Infected Ugandan Adults: Double-blind, Randomized and Placebo
Controlled Trial. Lancet, 35, (9221) 2106-11.
Klug, K., Madhi, S., Huebner, R., Kohberger, R., Mbelle, N., Pierce, N. (2003). A Trial of a 9-Valent Pneumococcal Conjugate Vaccine in Children
and Those without HIV Infection. The New England Journal of Medicine, 349, (14), 1341-1348
Louisiana Department of Health and Hospitals. Preventive Health: Immunization Schedule-2008. www.dhh.state.la.us/offices/publications
Mast et al (2006) A Comprehensive Immunization Strategy to Eliminate Transmission of Hepatitis B Virus Infection in the United States. MMWR,
55, RR-16, 12/8/06
Melvin, A. & Mohan, K. (2003) Response to Immunization with Measles, Tetanus, and Haemophilus influenzae Type b Vaccines in Children Who
Have Human Immunodeficiency Virus Type 1 Infection and Are Treated with Highly Active Antiretroviral Therapy. Pediatrics, lll, (6) 641-644.
Nachman, S., Kim, S., King, J., Abrams, E., Margolis, D., et al for the Pediatric AIDS Clinical Trials Group Study 292 Team. (2003) Safety and
Immunogenicity of a Heptavalent Pneumococcal Conjugate Vaccine in Infants with Human Immunodeficiency Virus Type 1 Infection. Pediatrics,
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Pancheron, C, Anaworanich, J., & Thisyakorn, U. (2004). Immunization for Persons Infected with Human Immunodeficiency Virus. Current HIV
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Salmon, D., Moulton, L. Omer, S., Chace, L., Klassen, A., Talebian, P., & Halsey, N., (2004) Knowledge, Attitudes, and Beliefs of School Nurses and
Personnel and Associations with Nonmedical Immunization Exemptions. Pediatrics, 113, (6), 552-559.
Spach, D., (2007) Immunizations for HIV-Infected Patients: Indications, Timing and Response. 9th Annual Ryan White Care Act Clinical Update, sli
presentation (Aug.28-30)
Spach, D., (2008) “Immunizations for HIV-Infected Patients”, slide presentation (April 30), New York.
Tasker, S, Treanor, J., Paxton, W., & Wallace, M. (1999) Efficacy of Influenza Vaccination in HIV-Infected Person: A Randomized, Double-Blind,
Placebo-Controlled Trial. Annals of Internal Medicine, 131, (6), 430-433.
The Journal Weekly Epidemiological Record (2007). Rotavirus Vaccines. (32), 82, 254-296.
U.S. Department of Health and Human Services (2007). Polio Immunization. www.cispinmmunize.org/ill/polio.html
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(The author would like to acknowledge the invaluable assistance of David Spach, MD, Northwest AETC, and
Ronald Wilcox, MD, Delta AETC.)

Sheryl Thornton is Nurse Educator, Delta Region AETC.


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