Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV

Overview

The Advisory Committee on Immunization Practices (ACIP) recommends immunizing people with HIV similarly to the general population, with a few key exceptions.

• The following live virus vaccines are contraindicated in people with HIV:
  • For any CD4 T lymphocyte (CD4) cell count
    • Live attenuated influenza (LAIV)
  • For CD4 count <200 cells/mm³ or uncontrolled HIV
    • Measles
    • Mumps
    • Rubella
    • Varicella (VAR)
    • Live attenuated typhoid Ty21a
    • Yellow fever
• The following vaccines have specific recommendations related to HIV status:
  • COVID-19
  • Hepatitis A (HAV)
  • Hepatitis B (HBV)
  • Meningococcus serogroup A, C, W, Y (MenACWY)
  • Pneumococcal vaccine

The National Institutes of Health (NIH)/Infectious Diseases Society of America (IDSA)/Centers for Disease Control and Prevention (CDC) recommendations described here may differ from ACIP recommendations when the committees interpret data differently or when one guideline has been updated more recently than the other.

Specific Immunizations

COVID-19 Vaccine

Whether people with HIV are at greater risk of acquiring SARS-CoV-2 infection is currently unknown. Data are emerging on the clinical outcomes of COVID-19 in people with HIV.

Worse outcomes for patients with HIV and COVID-19, including high COVID-19 mortality rates, have been reported in cohort studies from the United States, the United Kingdom, and South Africa.^1-10 HIV was independently associated with an increased risk of severe and critical COVID-19 in a large trial from the World Health Organization’s Global Clinical Platform, which included data from 24 countries.¹ In a multicenter cohort study of 286 patients with HIV and COVID-19 in the United States, lower CD4 T lymphocyte cell counts (i.e., <200 cells/mm³) were associated with a higher risk for the composite endpoint of intensive care unit admission, invasive mechanical ventilation, or death. This increased risk was observed even in patients who had achieved virologic suppression of HIV.²

All adults and adolescents should get the COVID-19 vaccine according to the most recent CDC recommendations regardless of their CD4 count or HIV viral load.^11,12 Those with severe immunosuppression may have a diminished immune response to the vaccine.^12,13 Routine serologic testing following vaccination is not recommended.¹⁴

COVID-19 is a rapidly evolving situation. For current COVID-19 vaccination recommendations, please visit CDC.gov.

Note: People with advanced or untreated HIV are considered moderately or severely immunocompromised. Advanced HIV is defined as people with CD4 counts <200 cells/mm³, a history of an AIDS-defining illness without immune reconstitution, or clinical manifestations of symptomatic HIV. Further information is available in the NIH COVID-19 Treatment Guidelines.

Hepatitis A Vaccine

See the “Hepatitis A virus (HAV)” section in the table below for detailed guidance on immunization against HAV.

Summary of Recommendations

For vaccination

• Administer a two-dose series (dosing interval depends on the vaccine used: at 0 and 6–12 months for Havrix^® or 0 and 6–18 months for Vaqta^®) of single-antigen hepatitis A vaccine (HepA) or a three-dose series (0, 1, and 6 months) of the combined hepatitis A and hepatitis B vaccine (HepA-HepB, Twinrix^®) to any person without evidence of immunity to HAV (and for the combined vaccine, without evidence of immunity to HAV or HBV) (AIII).
• For travelers, some clinicians recommend a four-dose accelerated regimen (days 0, 7, 21–30 days, and 12 months) of HepA-HepB (AIII).
• Assess antibody response 1 to 2 months after completion of the series. If negative, revaccinate when CD4 count is >200 cells/mm³(BIII).
• People with HIV presenting with CD4 cell count <200 cells/mm³with ongoing risk for HAV should be immunized and assessed for antibody response 1 to 2 months after completion of the series. For people with HIV without risk factors, waiting for CD4 >200 cells/mm³ is an option. Assess antibody response 1 to 2 months after completion of the series. If negative, revaccinate when CD4 cell counts are >200 cells/mm³(BIII).

For pre-exposure prophylaxis (travel)

• For people with HIV who are non-immune and are traveling within 2 weeks to countries with endemic HAV, consider administering immunoglobulin G (IgG) 0.1 mL/kg if duration of travel is <1 month. If duration of travel is 1 to 2 months, then administer IgG 0.2 mL/kg. If duration of travel is ≥2 months, IgG 0.2 mL/kg should be repeated every 2 months.

For post-exposure prophylaxis

• For people with HIV who are non-immune, administer HAV vaccine and IgG 0.1 mL/kg simultaneously in different anatomical sites as soon as possible, ideally within 2 weeks of exposure.

Hepatitis B Vaccine

See the “Preventing Disease” section in Hepatitis B Virus (HBV) Infection for detailed guidance on immunization against HBV, as well as the evidence summary.

Summary of Recommendations

For vaccination

• For people with HIV who are non-immune to HBV (surface antibody titer negative) and do not have chronic HBV infection (surface antigen negative), administer a three-dose series of recombinant hepatitis B vaccine (Engerix^® 40 mcg [2 injections of 20 mcg each] or Recombivax^® 20 mcg [2 injections of 10 mcg each]) at 0, 1, and 6 months (AII). These doses are considered “double-dose,” three‑dose series.
• A two-dose (0 and 1 month) recombinant hepatitis B vaccine that uses a toll-like receptor 9 immunostimulatory adjuvant (HepBCpG, Heplisav-B^®) can also be used. Observational data in individuals with HIV suggest superior response rates. A randomized controlled trial of Heplisav-B in people with HIV is enrolling currently. If a two-dose vaccine is preferred, Heplisav-B^® is an option for vaccinating people with HIV (CIII).
• Anti-HBs should be obtained 1 to 2 months after completion of the vaccine series. People with anti-HBs ≥10 mIU/mL are vaccine responders.
• Because of waning immunity, some experts would check anti-HBs annually and would give a booster dose if levels fall below 10mIU/mL, particularly if patients have ongoing risk factors for acquiring HBV and are not receiving tenofovir.
• For people with HIV who do not respond to a complete HepB vaccination series—
  • Revaccinate with a second double-dose, three-dose vaccine series of recombinant HBV vaccine (Engerix-B^® 40 mcg [2 injections of 20 mcg each] or Recombivax HB^® 20 mcg [2 injections of 10 mcg each]) (BIII). Some experts consider that a double-dose, four-dose vaccine series of recombinant hepatitis B vaccine (Engerix-B^® 40 mcg [2 injections of 20 mcg each] or Recombivax^® 20 mcg [2 injections of 10 mcg each] at 0, 1, 2, and 6 months) may produce a better immunologic response, but this approach has not been demonstrated to be superior to a double-dose, three-dose series; or
  • Administer a two-dose series of HepBCpG (Heplisav-B^®) (BIII).
• For people with low CD4 count at the time of first vaccination series, some experts might delay revaccination until after the CD4 count is ≥200 cells/mm³(CIII).
• For individuals with isolated hepatitis B core antibody (anti-HBc), vaccinate with one standard dose of HBV vaccine (BII) and check anti-HBs titers 1 to 2 months afterward (BII). If the anti-HBs titer is ≥100 mIU/mL, no further vaccination is needed. If the titer is <100 mIU/mL, then complete another series of HBV vaccine (double dose) followed by anti-HBs testing (BII). If titers are not available, then give a complete vaccine series followed by anti-HBs testing (BII).

For post-exposure prophylaxis

• For exposed people who have been vaccinated previously with a complete HepB vaccine series and have documented antibody response, no additional vaccine is needed.
• For exposed people who have received a complete HepB vaccine series without documentation of antibody response, administer a single dose of HepB vaccine.
• For exposed people who have not received any HepB vaccine or have not received a complete HepB vaccine series, administer/complete HepB vaccine series and administer one dose of hepatitis B immune globulin (HBIG) at a separate anatomical site as soon as possible after exposure (ideally within 24 hours, but up to 7 days after percutaneous exposure and up to 14 days after sexual exposure).
• For exposed non-immune people with HIV on tenofovir or lamivudine, HBIG may not be necessary.

Human Papillomavirus Vaccine

See the “HPV Vaccine” section in Human Papillomavirus (HPV) Disease for detailed guidance on immunization against human papillomavirus (HPV), as well as the evidence summary.

Summary of Recommendations

• Routine HPV vaccination is recommended for people with HIV. Ideally, the series should be initiated at age 11 or 12 years but may be started as early as age 9 years. For all people with HIV aged 13 to 26 years who were not vaccinated previously, regardless of gender, administer three doses of the recombinant HPV nonavalent vaccine (Gardasil^®9) at 0, 1 to 2, and 6 months (AIII). The two-dose series is not recommended in people with HIV.
• For people with HIV aged 27 to 45 years not adequately vaccinated previously, HPV vaccine is not routinely recommended; instead, shared clinical decision-making regarding HPV vaccination is recommended.
• At present, vaccination with commercially available HPV vaccine is not recommended during pregnancy (CIII).
• For people who have completed a vaccination series with the recombinant HPV bivalent or quadrivalent vaccine, some experts would consider additional vaccination with recombinant HPV nonavalent vaccine, but data are lacking to define the efficacy and cost-effectiveness of this approach (CIII).

Influenza Vaccine

Summary of Recommendations¹⁵

• For all adults and adolescents with HIV, administer age-appropriate inactivated influenza vaccine or recombinant influenza vaccine annually (AI).
• For pregnant individuals with HIV, administer inactivated influenza or recombinant vaccine at any time during pregnancy (AI).
• The live attenuated influenza vaccine (LAIV) administered via nasal spray is contraindicated in people with HIV (AIII).
• High-dose and adjuvanted influenza vaccines are recommended for people with HIV aged 65 years or older over standard-dose unadjuvanted vaccines (AII).

Evidence Summary

Influenza is a common respiratory disease in adults and adolescents. Annual epidemics of seasonal influenza typically occur in the United States between October and April. Influenza A and B are most frequently implicated in human epidemics. Influenza A viruses are categorized into subtypes based on characterization of two surface antigens: hemagglutinin (HA) and neuraminidase (NA). Although vaccine-induced immunity to the surface antigens HA and NA reduces the likelihood of infection,^16,17 the frequent emergence of antigenic variants through antigenic drift¹⁸ (i.e., point mutations and recombination events within a subtype) is the virologic basis for seasonal epidemics and necessitates revaccination each season.¹⁹

Some studies of influenza have noted higher hospitalization rates^20-23 and increased mortality^23,24 among people with HIV; however, these findings have not been observed in all settings.²⁵ Increased morbidity may be greatest for people with HIV not on antiretrovirals (ARV) or with advanced disease. People with HIV are at high risk of serious influenza-related complications. For more information, see the CDC’s webpage on Flu & People Living with HIV.

In general, people with HIV with minimal AIDS-related symptoms and normal or near-normal CD4 counts who receive inactivated influenza vaccine (IIV) develop adequate antibody responses.^26-28 Among people with low CD4 counts or who have advanced HIV disease, IIV might not induce protective antibody titers.^28-30 In one study, markers of inflammation in older people (≥60 years) with HIV were associated with lower post-vaccination influenza antibody titers.³¹ In people with HIV, a second dose of vaccine does not improve immune response,^29,32 and intradermal influenza vaccine dosing did not improve the immune response compared with intramuscular dosing.³³

Two clinical studies have evaluated influenza vaccine efficacy in people with HIV. In an investigation of an influenza A outbreak at a residential facility for people with HIV,²⁰ vaccination was most effective at preventing influenza-like illness among people with >100 CD4 cells/mm³ and among those with HIV RNA <30,000 copies/mL. In a randomized placebo-controlled trial conducted in South Africa among 506 individuals with HIV, including 349 people on ARV treatment and 157 who were ARV treatment-naive, efficacy of trivalent IIV for prevention of culture- or RT-PCR–confirmed influenza illness was 75% (95% confidence interval, 9% to 96%).³⁴

Several clinical studies also have evaluated the immunogenicity of influenza vaccine in people with HIV. In a randomized study³⁵ comparing the immunogenicity of high-dose (60 mcg of antigen per strain) versus standard-dose (15 mcg of antigen per strain) trivalent IIV among 195 adults with HIV aged ≥18 years (10% of whom had CD4 counts <200 cells/mm³), seroprotection rates were higher in the high-dose group for influenza A (96% versus 87%; P = 0.029) and influenza B (91% vs. 80%; P=0.030). However, in a comparative study of 41 children and young adults aged 3 to 21 years with cancer or HIV, high-dose trivalent IIV was no more immunogenic than the standard dose among the recipients with HIV.³⁶

Optimally, influenza vaccination should occur before onset of influenza activity in the community because it takes about 2 weeks after vaccination for protective antibodies to develop.¹⁵ Health care providers should offer vaccination by the end of October if possible, and vaccination should continue to be offered as long as influenza viruses are circulating.

Although booster doses can make the influenza vaccine more effective, that benefit is limited to specific groups, such as solid-organ transplant recipients.³⁷ One study in people with HIV assessed the effectiveness of a two-dose regimen of IIV and found that the second dose of vaccine did not significantly increase the frequency or magnitude of antibody responses.³² Based on this study, influenza booster immunizations are not recommended for people with HIV.

Many licensed injectable influenza vaccine options are available, with no recommendation favoring one product over another.¹⁵ Information on currently available influenza vaccines is obtainable through the CDC recommendation, “Prevention and Control of Seasonal Influenza with Vaccines.” For adults aged ≥65 years, high-dose IIV,³⁸ adjuvanted IIV,³⁹ or recombinant influenza vaccine⁴⁰ are preferentially recommended over standard-dose unadjuvanted vaccines based on data suggesting higher efficacy in preventing invasive pneumococcal disease in this age group.⁴¹

Influenza vaccines are quadrivalent (two A components and two B components) with formulations that change from season to season. Although a quadrivalent live attenuated influenza vaccine (LAIV4) is available, it is contraindicated for people with HIV because of the paucity of safety data and the availability of alternative vaccines.¹⁵ Although unintentional administration of LAIV4 to adults with HIV has been well tolerated,⁴²it is not recommended for people with HIV.

IIVs can be administered to people receiving influenza antiviral drugs for treatment or chemoprophylaxis. Concurrent administration of influenza vaccine does not interfere with the immune response to other inactivated vaccines or to live vaccines.

Measles, Mumps, and Rubella Vaccine

Summary of Recommendations

For vaccination

• Administer two doses of measles, mumps, and rubella vaccine (MMR) at least 1 month apart to people with a CD4 count ≥200 cells/mm³ and who have no evidence of immunity to measles, mumps, and rubella (evidence of immunity is defined as: patient was born before 1957, and/or had documentation of receipt of MMR, and/or has laboratory evidence of immunity or disease) (AIII).
• The MMR vaccine is contraindicated during pregnancy.
• People of childbearing potential who get the MMR vaccine should wait 4 weeks before getting pregnant.
• For pregnant people without immunity to rubella, delay immunization until after pregnancy, then administer two doses of the MMR vaccine at least 1 month apart if the CD4 count is ≥200 cells/mm³(AIII).
• If no serologic evidence of immunity exists after two doses of MMR vaccine, consider repeating the two-dose MMR series, especially the person if vaccinated while not virologically suppressed (CIII).
• Do not administer MMR vaccine to people with HIV with CD4 count <200 cells/mm³(AIII).

For post-exposure prophylaxis

• For measles exposure of non-immune individuals with CD4 count >200 cells/mm³, administer the MMR vaccine within 72 hours of exposure or immunoglobulin (IG) within 6 days of exposure. Do not administer the MMR vaccine and IG simultaneously.
• For measles exposure of non-immune individuals with CD4 count <200 cells/mm³ or those who are pregnant, administer IG within 6 days of exposure.

Evidence Summary

Measles is particularly virulent in the immunocompromised host, with a reported mortality rate as high as 40% in people with advanced HIV.⁴³ Recently, measles outbreaks have occurred across the United States. From January 1 to October 3, 2019, 1,250 individual cases of measles were confirmed in 31 states: the most cases in 25 years. Current information regarding outbreaks can be found on the CDC website Measles Cases and Outbreaks. Measles is a highly contagious and potentially life-threatening disease.

With a resurgence of measles both domestically⁴⁴ and globally,⁴⁵ people with HIV should be assessed for immunity. Acceptable evidence of immunity includes being born before 1957, documented evidence of two doses of the MMR vaccine, or presence of positive antibody titers.

Individuals who do not fulfill any criteria for immunity and have CD4 count ≥200 cells/mm³ should receive two doses of MMR separated by at least 28 days. The combination measles, mumps, rubella, and varicella (MMRV) vaccine has not been studied in immunocompromised hosts and should not be administered to people with HIV.

Several studies from the 1990s found that approximately 90% to 95% of adults with HIV were immune to measles.^46-48 In these studies, serostatus did not vary by CD4 count, suggesting people with HIV retained protective immunity even in the context of advanced disease. However, in a more recent study, the measles seroprevalence rate was 70.3%.⁴⁹ Similarly, people with HIV appear to retain immunity to mumps and rubella even after acquisition of HIV.⁴⁹

MMR vaccine is contraindicated for people with HIV with CD4 count <200 cells/mm³ because MMR vaccine is a live attenuated formulation that has been linked to fatal cases of measles-associated pneumonitis following administration to people with HIV with low CD4 counts.^50,51 For people with HIV with CD4 count ≥200 cells/mm³, the vaccine has been shown to be safe, although antibody response may be lower than for patients without HIV.^49,52,53

For more detailed information regarding post-exposure prophylaxis, please see Measles (Rubeola).

Meningococcal Vaccine

Summary of Recommendations

• Administer two doses of quadrivalent meningococcal conjugate vaccine, at least 8 weeks apart to all people with HIV age ≥18 years (AII).
• For people with HIV receiving primary vaccination, administer two doses given at least 8 weeks apart.
• For individuals with HIV who have been vaccinated previously and are age ≥7 years, repeat vaccination every 5 years throughout life (BIII).
• Serogroup B meningococcal vaccination (MenB) is not routinely indicated for adults and adolescents with HIV at this time.

Evidence Summary

Meningococcal meningitis, caused by Neisseria meningitidis, is the most common cause of bacterial meningitis among children and young adults in the United States. Surveillance data collected from 1998 to 2007 identified 2,262 cases of meningococcal disease from a sample of 13% of the U.S. population from several states. All available formulations of meningococcal vaccine are inactivated. Three quadrivalent meningococcal conjugate (MenACWY) vaccines are currently licensed and available in the United States: (1) Meningococcal groups A, C, W, and Y polysaccharide diphtheria toxoid conjugate vaccine (MenACWY-D, Menactra^®); (2) Meningococcal groups A, C, W, and Y oligosaccharide diphtheria CRM197 conjugate vaccine (MenACWY-CRM, Menveo^®); and (3) Meningococcal groups A, C, W, and Y polysaccharide tetanus toxoid conjugate vaccine (MenACWY-TT, MenQuadfi^®). These vaccines are recommended for all adolescents aged 11 to 18 years and people aged 2 to 55 years who are at increased risk for disease.

A growing body of evidence supports an increased risk of meningococcal disease in people with HIV. Studies have shown a 5- to 24-fold increased risk of meningococcal disease in people with HIV compared with people without HIV; low CD4 count and high HIV viral load are associated with increased risk.⁵⁴ The average annual incidence rate of invasive meningococcal disease was 0.39 cases per 100,000 people. People with HIV with lower CD4 counts are at higher risk of invasive disease.⁵⁵ In addition, a cohort study found that uptake of the MenACWY vaccine among people with a new diagnosis of HIV infection was low and time to receipt of first vaccination was long.⁵⁶

The safety and immunogenicity of MenACWY-D vaccine have been evaluated only in people with HIV aged 11 to 24 years. Patients with CD4% ≥15% received either one or two doses (at 0 and 24 weeks) of vaccine, and those with CD4% <15% received two doses (at 0 and 24 weeks). Among people with HIV who received one dose of vaccine, 21% to 63% developed an antibody titer of ≥1:128 at 72 weeks after vaccination. Antibody responses at 72 weeks in individuals with CD4% <15% were less robust,⁵⁷ with only 6% to 28% achieving titers ≥1:128. Local site reactions—such as pain and tenderness at injection site—were uncommon (3.1%) as were grade 3 or greater events (2.2%). No vaccine-related deaths or cases of meningitis were noted. No safety or immunogenicity studies are available for MenACWY-CRM in people with HIV, and clinical outcome data for both vaccines in people with HIV are lacking as well.

Menactra^®, Menveo^®, and MenQuadfi^® are recommended for all adults with HIV, regardless of age.

MenB is not routinely indicated for adults and adolescents with HIV at this time. MenB vaccine may be administered to adolescents and young adults with HIV aged 16 to 23 years (preferred range, ages 16–18 years) for short-term protection against most strains of serogroup B meningococcal disease and for patients at increased risk (e.g., those living in dormitories or barracks) and during outbreaks. Those with functional or anatomic asplenia should also be vaccinated. For more information, see the CDC’s webpage on Asplenia and Adult Vaccination. Two MenB vaccines are available, MenB-4C (Bexsero^®; two-dose series given at 0 and 1 month) and MenB-FHbp (Trumenba^®; people with HIV should receive the three-dose series given at 0, 1–2, and 6 months and not the two-dose option). MenB vaccines are not interchangeable; the same product must be used for all doses in the series.

Urban outbreaks of meningococcal meningitis have been reported among men who have sex with men in the United States, in men both with and without HIV. Several outbreaks were associated with clubs and bathhouses. Some public health jurisdictions now recommend meningococcal vaccine for all men who have sex with men, regardless of HIV status; however, ACIP has not adopted this recommendation for men who have sex with men without HIV.⁵⁸

Pneumococcal Vaccine

See the “Preventing Disease” section in Community-Acquired Pneumonia for detailed guidance on immunization against pneumococcal disease, as well as the evidence summary.

Summary of Recommendations

For all people with HIV without history of pneumococcal vaccination or unknown vaccine history:

• Administer either 15-valent pneumococcal conjugate vaccine (PCV15) or 20-valent pneumococcal conjugate vaccine (PCV20)(AII).
• If PCV15 is used, a dose of 23-valent pneumococcal polysaccharide vaccine (PPSV23) should be administered at least 8 weeks later(AII). No additional pneumococcal vaccine doses are recommended.

For people with HIV who previously started or completed a pneumococcal vaccination series, there is no need to restart the series.

• People with HIV who previously received only the 13-valent pneumococcal conjugate vaccine (PCV13) should receive PPSV23 at least 8 weeks later(BIII).
• People with HIV who have received PCV13 and PPSV23 should receive a booster PPSV23 at least 5 years after the first dose. If they were <65 at the time of the second dose, they should receive a third and final dose at or after age 65, at least 5 years after the second PPSV23 dose (BIII).
• People with HIV who have only received PPSV23 may receive a PCV (either PCV20 or PCV15) ≥1 year after their last PPSV23 dose. When PCV15 is used in those with history of PPSV23 receipt, it need not be followed by another dose of PPSV23 (BIII).

Tetanus, Diphtheria, and Pertussis Vaccine

Summary of Recommendations

• Administer the combination tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) once if person with HIV had not been vaccinated at age 11 or older, and then tetanus and diphtheria toxoids vaccine (Td) or Tdap every 10 years thereafter (AII).
• For pregnant individuals with HIV, administer one dose of Tdap during each pregnancy, preferably between 27 weeks and 36 weeks gestation (AIII).
• For adolescents and adults with HIV who have not received primary vaccination series for tetanus, diphtheria, or pertussis, administer one dose of Tdap followed by one dose Td or Tdap at least 4 weeks after Tdap, and another dose Td or Tdap 6 months to 12 months after the last Td or Tdap. Tdap can be substituted for any Td dose but is preferred as the first dose (AIII).

Evidence Summary

Antibody response to tetanus and diphtheria vaccination varies by CD4 count. For individuals with advanced HIV and low CD4 counts, immunologic response is attenuated for both tetanus and diphtheria when compared to HIV-uninfected controls.^59,60 For people with CD4 counts >300 cells/mm³, antibody response to tetanus vaccination is similar to the general population, whereas response to diphtheria remains diminished.^59-61 Limited data exist on the efficacy of pertussis vaccination in this population.

Two Tdap vaccines for individuals aged ≥10 years are available in the United States (Adacel^® and Boostrix^®). Both vaccines are inactivated and considered safe to administer at any CD4 count. People with HIV should receive vaccination for tetanus, diphtheria, and pertussis on the same schedule as individuals without HIV. All adults not previously vaccinated should receive a single dose of Tdap, followed by a Td or Tdap booster every 10 years.

Varicella Vaccine

See “Vaccination to Prevent Primary Infection (Varicella)” in the Varicella-Zoster Virus Disease section for detailed guidance on immunization against varicella, as well as the evidence summary.

Summary of Recommendations

• People with HIV with any of the following have presumed immunity to varicella: receipt of two doses of varicella vaccine (VAR or MMRV), diagnosis of varicella or herpes zoster (shingles) by a health care provider, or laboratory evidence of immunity or disease.
• For people with HIV who are varicella non-immune with CD4 count ≥200 cells/mm³, administer two doses of VAR 3 months apart (BIII).
• VAR is contraindicated for people with HIV with CD4 count <200 cells/mm³(AIII).

Herpes Zoster Vaccine

See “Vaccination to Prevent Re-activation Disease (Herpes Zoster)” in the Varicella-Zoster Virus Disease section for detailed guidance on immunization against zoster, as well as the evidence summary.

Summary of Recommendations

• For people with HIV ≥18 years, administer two doses of recombinant zoster vaccine (RZV) at 0 and 2 to 6 months (AIII).
• Consider delaying vaccination until the patient is virologically suppressed on ART (CIII) or until the CD4 count >200 cells/mm³ to ensure a robust vaccine response (CIII).
• People with HIV ≥18 years should receive RZV regardless of previous history of herpes zoster or previous receipt of zoster vaccine live (no longer available).

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