Live vaccines
Live Vaccines
Measles, mumps and rubella vaccine
Varicella vaccines
Zoster vaccine
The use of live vaccines is contra-indicated in HIV-infected adults especially if the CD4+ count is below 200 cells/μL, and/or there is clinical evidence of acquired immunodeficiency syndrome (AIDS). There is evidence that for some live vaccines there is a potential for the proliferation of vaccine-related viruses in the host, varicella as an example 69,70.
MEASLES , MUMPS AND RUBELLA VACCINE
Measles, mumps and rubella (MMR) vaccines are live, and therefore, contra-indicated in individuals with CD4+ counts below 200 cells/µL.
The ACIP has since 2013 made recommendation about the use of MMR vaccine in HIV-infected adults, provided the CD4+ counts are above 200 cells/μL, without laboratory evidence of immunity or past disease 71. A retrospective study from the USA assessing the MMR serostatus of HIV-infected adults, reported that 15% of HIV-infected adults are seronegative. A seronegative MMR status was associated with a longer duration of HIV infection, younger age and those born after 1957. This study also reported that about 50% of HIV-infected adults seroconverted after MMR vaccination. This study found that MMR vaccination did not lead to progression of HIV disease, nor did it impact on HIV disease control 71. This study therefore demonstrated the safety and efficacy of MMR vaccination in HIV-infected adults with CD4+ counts above 200 cells/μL and undetectable viral loads.
Most international guidelines recommend MMR vaccination in non-immune adults infected with HIV with a CD4+ cell count above 200 cells/μL 28,71.
VARICELLA VACCINES
It is estimated that 4.2 million cases of severe varicella infection globally result in hospitalisation or death. Varicella zoster virus (VZV) infections and related deaths are common in HIV-infected individuals. Most HIV-infected adults will have evidence of prior infection or immunity. There is an effective vaccine for varicella which is in use in high income countries. There are limited data on varicella vaccination in HIV-infected adolescents or adults, although one study has reported on the safety and modest immunogenicity of two doses of varicella vaccine in HIV-infected adults with a CD4+ count above 400 cells/μL with a suppressed viral load 72. At present in Africa there is a lack of varicella epidemiology and socio-economic data on the impact of this disease. Therefore, there are no data on which to base recommendations regarding the use of this vaccine in HIV-infected adults 73.
ZOSTER VACCINE
Reactivation of latent varicella-zoster virus infection leads to a debilitating condition: herpes zoster (HZ; known as shingles). Despite the increased uptake and use of ART the incidence of herpes zoster remains increased in HIV-infected adults. The increased uptake of ART has also resulted in a greater proportion of HIV-infected people living beyond the age of 50 years 7,74,75.
The use of varicella vaccine is recommended in varicella-susceptible adults, as long as they have a CD4+ count above 200 cells/µL, the same CD4+ threshold used for MMR and yellow fever vaccines. No transmission of vaccine strain varicella zoster virus has been documented in people with HIV infection with a CD4+ count above this threshold. The administration of LAHZV to 295 HIV-infected adults with a CD4+ count above 200 cells/µL was found to be safe and immunogenic, with no cases of vaccine strain infection 74,76.
At present there are no epidemiological data to support the use of this vaccine in Africa. There is a systematic review underway to assess the morbidity and mortality of varicella zoster virus infection 73. Until more evidence becomes available we do not recommend this vaccine for HIV-infected adults.