Pneumococcal vaccination in HIV infected adults - would choice of vaccine differ?

J Infect Dis. 2010 Oct 1;202(7):1114-25.
http://www.ncbi.nlm.nih.gov/pubmed/20795819

In HIV infected patients, risk of pneumococcal infection is high and vaccination is recommended.  
The 23-valent pneumococcal vaccine is generally recommended for HIV-infected patients - previously recommended for patients with CD4 counts ≥200 cells/mm³, studies evaluating its efficacy have yielded mixed results (ACC Sep 1 2000, Jan 1 2001, and Jul 27 2005). Then, a study from AIDS clinical care suggested that protection benefit may be greatest in patients with CD4 <200 (http://www.medscape.com/viewarticle/563686). 


Nevertheless, immune response, even after revaccination with the 23-valent polysaccharide vaccine (PPV) are low among human immunodeficiency virus (HIV)-infected adults.

This study determined whether revaccination with the 7-valent pneumococcal conjugate vaccine (PCV) would enhance these responses.  HIV patients (median CD4 533cells/mm3 who's had PPV 3 - 8 years earlier were compared with non-HIV infected population, revaccinated wtih PCV or PPV.

RESULTS: HIV-infected persons demonstrated a higher frequency of positive antibody responses to PCV than to PPV (57% vs 36%) (P = .004) and greater mean changes in the immunoglobulin G concentration from baseline to day 60 for serotypes 4, 9V, and 19F (P < .05, for all), but not for serotype 14. However, by day 180, both outcomes were similar. Responses to PCV were greater in frequency and magnitude for all serotypes in HIV-uninfected adults, compared with those in HIV-infected adults.

CONCLUSIONS FROM AUTHOR: Among persons with HIV infection, revaccination with PCV was only transiently more immunogenic than PPV, and responses were inferior to those in HIV-uninfected subjects with primary vaccination. Pneumococcal vaccines with more robust and sustained immunogenicity are needed for HIV-infected adults.

What does the current 2009 AIDS guideline say:
Guideline now recommends pneumococcal vaccination when CD4 <200, but efficacy is not yet fully established. Re-vaccination after immune reconstitution CD4>200 can be considered but efficacy and duration of protection is not fully known. Revaccination every 5 years may be considered although definite data supporting this recommendation is lacking.