HIV and ID Observations

The CDC’s Advisory Committee on Immunization Practices has just released the “official” guidelines for use of the zoster vaccine. And none too soon — if I had a dollar (or these days, make that a euro) for every curbside consult I’ve received about the zoster vaccine …

The vaccine’s indications are simple — age over 60, immunocompetent. Ah, but the devil is in the details, and that’s what make these guidelines so helpful.

Readers will find answers to many common questions about zoster vaccine, including:

1. Should it be given to people younger than 60? Not at this point. It’s unlikely to be harmful, however, and I suspect some practitioners might stretch this age criterion downward, especially for patients who particularly fear getting shingles.
2. Should it be given to people older than 80? Yes — although the vaccine appears not to work as well in this group. Still, not all 80-year-olds are created equal, and undoubtedly, some would respond and be protected.
3. Should it be given to people who have already had zoster? Yes — but remember this group wasn’t in the licensing study. But it won’t be harmful and might help. And boy, do people who have had zoster want this vaccine.
4. What about people who are taking antivirals with activity against VZV? Have them stop these antivirals for at least 14 days after getting vaccinated. (I love it when guidelines give precise information like this. And 14 days fits nicely into the “multiples of days of the week or fingers of the hand” rule that ID docs love.)
5. Should we worry about secondary transmission of the vaccine’s virus? Generally not. Yet I guarantee we’ll still get calls on this one: “Hi Paul, my patient is visiting his baby grandson this weekend — is it safe to give him the zoster vaccine?” or “My patient’s husband is on chemo for CLL — should she get it?” or “He’s flying coach to Australia and will be on a jet for 15 hours — can he get the vaccine?”  (Yes and yes and yes, by the way.)
6. Can we give it to people who can’t remember whether they had chicken pox? So long as they were born before 1980, the answer is yes — in all likelihood, they did have chicken pox and hence are at risk for zoster. (All people older than 60 were indeed born before 1980 — hey, I knew that pre-med calculus would come in handy someday.)
7. What immunocompromised patients should not get the vaccine? Basically, those with impaired cellular immunity shouldn’t get it, and the guidelines offer a nice summary of who these folks are.

Which brings me to what I found most surprising about the guidelines — the reference to its use in those with HIV. I anticipated that the guidelines would say the vaccine is contraindicated for everyone with HIV, but instead they specify that the vaccine should not be given to:

“Persons with AIDS or other clinical manifestations of HIV, including persons with CD4+ T-lymphocyte values <200 per mm³ or <15% of total lymphocytes”

But does this mean we should give it to all our asymptomatic HIV patients with CD4s > 200/15%? Just those over age 60? Just those who’ve never been < 200/15%? All, some, or none of the above? These guidelines don’t say.

Clearly, this vaccine is of interest to HIV providers and their patients: the incidence of zoster is at least 15-fold higher in people with HIV, and of course, zoster can occur at any CD4-cell count.

Fortunately, an ACTG study is planned evaluating the zoster vaccine in people with HIV. Stay tuned.