Case: A 26-Year-Old Man With HIV Infection

Question 1 of 7

DS is a 26-year-old man transferring care for HIV infection from an outside practitioner. He was diagnosed with HIV infection 1 year prior to his visit and his CD4+ cell count nadir at the time of diagnosis was 84/µL (CD4+ cell percentage, 8%). He was started immediately on antiretroviral therapy with tenofovir alafenamide (TAF)/emtricitabine/elvitegravir/cobicistat (slash indicates a coformulation) as well as prophylaxis for opportunistic infections with trimethoprim/sulfamethoxazole. His last CD4+ cell count was obtained 1 week prior to his visit and was 162/µL (CD4+ cell percentage, 12%). His plasma HIV RNA level by polymerase chain reaction (PCR) assay at that time was below 20 copies/mL. He has no symptoms or physical findings at the time of the visit that are concerning for infection or other AIDS-related complications. He is a college student completing his senior year with plans to continue to graduate school next year. He is sexually active with men only and notes that many partners in the last year were HIV seropositive. He reports having received all of his childhood immunizations including the varicella vaccine. His last tetanus shot was at age 16 years following a puncture to his foot with a dirty nail. He notes receiving a flu shot last year but he was told that he should wait on other vaccines until his body gets stronger.

Review of his hepatitis serologies shows that he is negative for the hepatitis A total antibody, the hepatitis B core antibody, the hepatitis B surface antigen, and the hepatitis c antibody; his hepatitis B surface antibody (HbsAb) test result is below 10 mIU/mL.

Clinical Decision Point A

What would be the most important vaccines to recommend for him today?

Defer all vaccines until his CD4+ cell count is above 200/µL.
An approved trivalent or quadrivalent intramuscular influenza vaccine, 23-valent pneumococcal polysaccharide vaccine (PPSV23), given a high risk for pneumonia, and the meningococcal conjugate (MenACWY) vaccine. Consider deferring other vaccines until his CD4+ cell count is above 200/µL, based on assessed risk.
An approved trivalent or quadrivalent intramuscular influenza vaccine, 13-valent pneumococcal conjugate vaccine (PCV13), given the high risk for pneumonia, and MenACWY. The urgency of other vaccines may be evaluated based on his assessed risk.
Conjugate vaccines only (PCV13 and MenACWY), given the risks of viral vaccines and the lower immunogenicity of simple polysaccharide and recombinant protein vaccines.
PCV13, MenACWY vaccine, and intranasal influenza vaccine

Question 2 of 7

Clinical Decision Point B

The patient agrees to get the influenza, pneumococcal, and meningococcal vaccines at this visit. The practitioner discusses the specific forms available and recommendations with him.

Based on the DHHS, IDSA, ACIP, and CDC vaccination guidelines, what form of influenza vaccine should be recommended?

Intranasal live inactivated virus vaccine.
Standard-dose intramuscular trivalent or quadrivalent vaccine.
High-dose intramuscular vaccine if CD4+ cell count is below 200/µL.
Standard-dose intramuscular vaccine with a booster dose after 1 month.
An intramuscular and intranasal vaccine administered simultaneously.

Question 3 of 7

Clinical Decision Point C

Given the higher risk of meningococcal disease in persons living with HIV infection and AIDS, the patient has agreed to meningococcal vaccination as part of his vaccinations during this visit. What form of meningococcal vaccine would be indicated for this patient?

Recombinant meningococcus serogroup B vaccine.
Meningococcal conjugate (MenACWY) vaccine.
Polysaccharide meningococcus ACWY vaccine.
The conjugate vaccine or the polysaccharide vaccine would be acceptable.

Question 4 of 7

Clinical Decision Point D

You are advising the patient regarding the recommendations for further pneumococcal vaccination after his PCV-13 dose. After what interval can PPSV23 be administered to him?

At his next visit, regardless of the interval.
A minimum of 8 weeks.
PPSV23 is not necessarily given because most strains of pneumococcus for which he is at risk are covered with the PCV13 vaccine.
5 years.
The need for PPSV23 should be assessed based on specific antibody titers.

Question 5 of 7

The patient returns to clinic several months later. His CD4+ cell count checked 3 months prior to the visit was 206/µL. He remains on antiretroviral therapy and has been tolerating it well. He reports no recent infections or symptoms and his examination showed no new findings of concern.

You discuss additional immunizations for hepatitis A, hepatitis B, tetanus, and HPV. He is up to date with his tetanus vaccine as per standard recommendations.

Clinical Decision Point E

The patient does not have immunity to hepatitis A and B. What dose and schedule are recommended for the hepatitis A and hepatitis B vaccines?

Use of the combined hepatitis A and B vaccine using the regular or accelerated schedule is acceptable. Assessment of serologic response is not necessary given the adequate response rate with this regimen.
Hepatitis A and B vaccines should be given separately at standard doses using the regular or accelerated schedule. Assessment of serologic response is not necessary given the adequate response rate with this regimen.
Hepatitis A vaccine should be given with standard dosing and intervals. High-dose hepatitis B vaccine should be given separately using standard intervals. Response should be verified by serologic testing 1 month after the last dose.
Hepatitis A and B vaccines should be given separately at standard doses using the regular or accelerated schedule. However, serologic response to the hepatitis B vaccine should be assessed following completion to assure adequate response. Testing for serologic response to the hepatitis A vaccine is not necessary.
Hepatitis A vaccine should be given with standard dosing and intervals. Hepatitis B vaccine should be given in a 4-dose series with standard dosing.

Question 6 of 7

Clinical Decision Point F

The patient would like to be immunized against HPV. What form and schedule of HPV vaccine is recommended?

There is no benefit of immunization given that he has been sexually active for many years and likely has already been exposed.
The bivalent vaccine covers the most important strains associated with anal cancer and there is no additional benefit of immunization with the quadrivalent or 9-valent strains.
Either the quadrivalent or 9-valent strain would be recommended based on the guidelines.
The additional 5 strains included in the 9-valent vaccine are associated with cervical cancer only and immunization against them would not benefit him.
The vaccines are not sufficiently immunogenic in persons with HIV infection and their use is not recommended.

Question 7 of 7

Clinical Decision Point G

The patient has heard of persons with HIV infection having severe cases of shingles and asks if he would benefit from immunization against herpes zoster. Which statement regarding herpes zoster vaccination is correct?

The zoster vaccine is a live virus vaccine and is contraindicated in persons with HIV infection.
Zoster vaccination would be recommended regardless of age when an individual's CD4+ cell count is above 200/µL.
Persons with HIV viral suppression on treatment are at no increased risk of shingles and do not require immunization.
He will be eligible for the shingles vaccine when he turns 60 only if his CD4+ cell count is above 200/µL.
Based on his immunization history, he is not at risk for herpes zoster reactivation.

Case: A 26-Year-Old Man With HIV Infection