1. Methods of Infection Prevention in Advanced HIV Care Francesca Conradie President of the Southern African HIV Clinicians Society

2. Vaccines in HIV infected individuals A missed opportunity Immunogenicity. Overall, vaccines tend to be less immunogenic and antibody responses shorter lived In general, the earlier in HIV infection the better.

3. General considerations Detectable HIV RNA is associated decreased immunogenicity Should delay some until VL undectable.

4. What vaccines should HIV + persons receive? Inactivated vaccines recommended for the general adult population Inactivated seasonal influenza vaccine Tetanus toxoid and reduced diphtheria toxoid with or without acellular pertussis vaccine (Td or TdaP) Human papillomavirus vaccination (up to age 26 in HIV infected patients, if not received previously)

5. What vaccines should HIV + persons receive? Vaccines for which HIV is itself an indication Pneumococcal vaccination Hepatitis B virus vaccine (if not already immune)

6. What vaccines should HIV + persons receive? Other vaccines are recommended for HIV infected adults only if there is a specific indication or if there is evidence of no immunity Hepatitis A virus vaccine Meningococcal vaccination Haemophilus influenzae b vaccine Measles, mumps, rubella vaccine (if not already immune and CD4 cell count ≥200 cells/microL) Varicella vaccine (if not already immune and CD4 cell count ≥200 to 350 cells/microL)

7. Influenza vaccine Does not give you flu Inactivated vaccine formulation is recommended Live, intranasal vaccines should not be used in HIV infected patients Relative Risk 0.29 of acquiring flu. Yamanaka H, Teruya K, Tanaka M, et al. Efficacy and immunologic responses to influenza vaccine in HIV1infectedpatients. J Acquir Immune Defic Syndr 2005; 39:167.

8. Tetanus toxoid, diphtheria toxoid, and acellular pertussis vaccines Single dose (Tdap) for all who have not received Tdap Universal administration Td boosters every 10 years is also recommended HIV infected adults have similar antibody response to tetanus as an age matched normal population, but diphtheria immunity is lower than expected Transient increase in plasma HIV1 RNA levels after immunization with tetanus toxoid, but there were no long term consequences of this up regulation [16].

9. Human papillomavirus vaccination All adolescents (HIV infected and uninfected) at the ages of 11 or 12. Three formulations of HPV vaccine are available, – 9 valent (Types 6, 11, 16, 18, 31, 33, 45, 52, and 58) – Quadrivalent (Types 6, 11, 16, 18) – Bivalent (Types 16, 18) vaccines.

10. Pneumococcal vaccination Recommendations for PCV use (BHIVA) HIV-positive adults Single dose of PCV13 (polyvalent conjugate vaccine) irrespective of CD4 cell count, ART use, viral load At least 3 months after any use of PPSV23 (polysaccharide vaccineprime boost) Revaccination with PPSV23 at least five years PCV13 can be given at any CD4 cell count, but it may be preferable to defer PPSV23 administration until the CD4 cell count ≥200 PPSV23 only for >65 years or additional co-morbidities (other than HIV)

11. Hepatitis B Surface Antibody negative- non immune Surface Antigen positive- infected, needs treatment with 3TC and TDF – 40 μg/mL (Recombivax HB) administered on a 3- dose schedule or – 20 μg/mL (Engerix-B) administered on a 4-dose schedule at 0, 1, 2, and 6 month

12. Varicella Administer to HIV-infected persons with a CD4 count ≥200 cells/μL who do not have evidence of immunity to varicella. 0.5 mL IM as 2 doses administered 3 mo apart Post exposure prophylaxis following exposure to varicella zoster virus is indicated for HIV infected individuals who do not have immunity through natural infection or immunization.

13. Zoster vaccine Individuals with CD4 cell counts >350 cells had the highest zoster antibody levels post vaccination. High rates of injection site reactions in the zoster group It is reasonable to vaccinate those with CD4 counts >200 cells Zoster vaccine is specifically not recommended for HIV infected patients with a CD4 cell count <200

14. Conclusion Most of the vaccines are already available in the National rollout Need a systematic approach to adding into our ART program