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.

Use of HPV vaccine in HIV-infected men - Journal of Infectious Diseases

By Wilkin et. al. 2010

Use of HPV vaccine in men should be considered to prevent development of HPV related anal cancers. A

a single‐arm, open‐label, multicenter clinical trial was performed to assess the safety and immunogenicity of the quadrivalent HPV (types 6, 11, 16, and 18) vaccine in HIV‐1–infected men. 

Men with high‐grade anal intraepithelial neoplasia or anal cancer by history or by screening cytology or histology were excluded. Men received 0.5 mL intramuscularly at entry, week 8, and week 24. The primary end points were seroconversion to vaccine types at week 28, in men who were seronegative and without anal infection with the relevant HPV type at entry, and grade 3 or higher adverse events related to vaccination.

Results showed that vaccine was well tolerated, and showed successful seroconversion: for all 4 types: type 6 (59 [98%] of 60), type 11 (67 [99%] of 68), type 16 (62 [100%] of 62), and type 18 (74 [95%] of 78). No adverse effects on CD4 counts and plasma HIV‐1 RNA levels were observed.

Conclusions.The quadrivalent HPV vaccine appears safe and highly immunogenic in HIV‐1–infected men. Efficacy studies in HIV‐1–infected men, especially in preventing anal cancer, are warranted.   

http://www.journals.uchicago.edu/doi/abs/10.1086/656320