Immunizations and HIV

BACKGROUND

Individuals who have the human immunodeficiency virus (HIV) have weakened immune systems, making them susceptible to infections. Therefore, several vaccinations, or immunizations, are often recommended in HIV patients to prevent serious illnesses.

HIV is a retrovirus that causes AIDS (acquired immune deficiency syndrome). HIV is transmitted from person to person via bodily fluids, including blood, semen, vaginal discharge, penile secretions and breast milk. It can be spread by sexual contact with an infected person, by sharing needles/syringes with someone who is infected, or, less commonly (and rare in countries where blood is screened for HIV antibodies), through transfusions with infected blood.

The most obvious sign of HIV infection is a decrease in the number of CD4 cells (helper T-cells), which fight infection and are found in the blood. The virus slowly kills these cells without causing symptoms. Even when the infected individual is asymptomatic (experiences no symptoms), the virus is multiplying, infecting and destroying cells in the immune system. Once the patient's CD4 T-cell count is lower than 200 cells per microliter of blood, the infection has progressed to AIDS.

There is little clinical research on the effectiveness of immunizations in patients with HIV/AIDS. In general, immunizations are most effective in patients who have CD4 cell counts that are greater than 200 cells per microliter of blood. Patients who have CD4 cell counts lower than 200 cells per microliter of blood may have an impaired humoral response, and may not respond to vaccines or they may require supplemental doses to develop serologic evidence of protection. Healthcare providers can determine whether the vaccination is effective by performing a blood test for antibodies to the virus.

It is recommended that all HIV patients receive vaccines for the hepatitis B virus, influenza (flu), measles, mumps and rubella (MMR), polysaccharide pneumococcal pneumonia and tetanus and diphtheria. Other HIV patients, depending on their health, may also receive vaccines for the hepatitis A virus (HAV), both hepatitis A and B (Twinrix©), the Haemophilus influenzae type B infection and/or the meningococcal disease.

Live vaccines should not be administered to HIV/AIDS patients, especially in those who have low CD4 cell counts. Live viral vaccines (containing a live virus), such as small pox or varicella (chickenpox), should only be administered in HIV patients if the possible health benefits clearly outweigh the possible risks. This is because live viral vaccines can sometimes infect the recipient and can even sometimes infect those who come into close contact with a recently vaccinated individual. While this is not common, it occurs most often in individuals who have weakened immune systems.

VACCINATIONS RECOMMENDED FOR ALL HIV PATIENTS

Hepatitis B virus (HBV): It is recommended that all HIV patients receive the hepatitis B virus vaccine, unless there is evidence of immunity or active hepatitis. Patients will receive a series of three shots over the course of six months. The second dose is administered at least one month after the first dose. The third, and final dose, is administered at least two months after the second dose and at least four months after the first dose. All three doses are needed for the most effective and longest lasting immunity. A blood test should be performed once the immunization series is completed to check for HBV antibodies. A blood test should be performed once the immunization series is completed to check for HBV antibodies. If antibodies are present, the individual responded to the vaccine and is immune to the virus. Additional shots may be necessary if the antibody levels are too low. According to most scientific studies, about 30-60% of HBV vaccines are effective in HIV-positive patients, compared with 90% for HIV-negative individuals. New research suggests that the immunization may last up to 15 years.

The hepatitis B virus causes a serious liver infection. The infection can become chronic in some people and lead to liver failure, liver cancer, cirrhosis (a condition that causes permanent scarring and damage of the liver) or death. There are few treatment options for patients with chronic hepatitis B. In some cases, the doctor may suggest monitoring the patient's condition instead of treating it. In other instances, the doctor may recommend antiviral treatment. When liver damage is severe, a liver transplantation may be the only treatment option.

The hepatitis B virus is transmitted through contact with bodily fluids, such as blood, semen, vaginal discharge and breast milk, of someone who is infected . Even though HBV is transmitted by the same methods as HIV, hepatitis B is nearly 100 times as infectious as HIV. Individuals of any age, race, nationality, gender or sexual orientation can become infected with HBV.

Influenza (flu): It is recommended that all HIV patients receive an annual influenza (flu) vaccination. Only injectable flu vaccines should be administered in HIV patients because they are not live vaccines. The nasal spray vaccine (FluMist/LAIV©) should not be used because it contains a weakened form of the live influenza virus, and may infect HIV/AIDS patients who have compromised immune systems.

Patients who have HIV/AIDS and contract the flu have an increased risk of developing serious flu-related complications that affect the heart and lungs (like pneumonia) and are more likely to die from the infection than people who are not infected with HIV/AIDS. Other studies have shown that flu symptoms might last longer in HIV patients because they have weakened immune systems.

Measles, mumps and rubella (MMR): The only live vaccine recommended for HIV-infected patients is the measles, mumps and rubella (MMR) vaccine. People born before 1957 do not need to receive this vaccine. This is because People born in 1957 and before lived through several years of the measles epidemic before the first measles vaccine was developed. Studies show that 95-98% of individuals born before 1957 are immune to measles. HIV-positive adults with CD4 counts lower than 200 cells per microliter of blood, a history of AIDS-defining illness (an illness that is considered the first sign of the onset of AIDS) or clinical symptoms of HIV (like inflamed lymph nodes, fatigue, weight loss, frequent fevers and sweats, persistent or frequent yeast infections, persistent skin rashes or flaky skin, pelvic inflammatory disease in women and short-term memory loss) should not receive the MMR vaccine because the risk of developing MMR outweighs the benefits.

Each component of the MMR vaccine can be administered separately to achieve adequate antibody levels. Patients will receive one or two shots, depending on how many antibodies they produce after immunization.

Measles, mumps and rubella are highly communicable (contagious) viral infections, although rare in countries, such as the United States, where individuals have access to vaccinations. The infections are transmitted through airborne droplets. People become infected with the viruses when they inhale particles of infected sputum from the air. The viruses become airborne when an infected person expels saliva (when they cough, sneeze, talk, spit, etc.).

Measles is a virus that causes a rash, cough, runny nose, eye irritation, and fever in most people, but can also lead to pneumonia, seizures, brain damage, and death in some cases. The mumps virus causes fever, headache and swollen glands, but can also lead to deafness, meningitis, swollen testicles or ovaries and death in some cases. Rubella, also known as the German measles, is generally a mild disease, but can cause serious birth defects in the child of a woman who becomes infected while pregnant.

Polysaccharide pneumococcal (pneumonia): HIV-infected patients should receive the polysaccharide pneumococcal vaccine soon after they are diagnosed with HIV, unless they have been previously vaccinated within the last five years. The vaccine protects against 23 of the most common types of pneumococcal bacteria that cause pneumonia. If the patient's CD4 count is lower than 200 cells per microliter of blood when the vaccine is administered, the vaccine may be less effective because these individuals have weakened immune systems that may not be able to produce adequate levels of antibodies. In such cases, the vaccination should be repeated when CD4 count is greater than 200 cells per microliter of blood. Patients typically receive one or two shots every five years.

A bacterial infection in the lungs causes pneumonia, which is inflammation of the lungs. The Streptococcus pneumoniae bacterium commonly causes the illness. Pneumonia can range from mild to severe, depending on the causative bacteria and the patient's overall health. HIV/AIDS patients have an increased risk of developing severe pneumonia, which may be life threatening because they are immunocompromised.

Tetanus and diphtheria toxoid (Td): Tetanus and diphtheria toxoid (Td) administration is recommended in all HIV patients to prevent tetanus (lockjaw) and diphtheria (contagious infection of the throat). This vaccine is recommended in all individuals, whether they are immunocompromised or not. Patients receive one shot every 10 years.

Tetanus is a potentially fatal nervous system disease that is caused by the bacteria Clostridium tetani (C. tetani). The bacteria are commonly found in soil and in the gastrointestinal tract of animals. Infection begins when the bacteria spores enter the body through an open wound. The spores release active bacteria, which produces a poison called tetanospasmin that is released into the bloodstream. Tetanospasmin blocks nerve signals from the spinal cord to the muscles, causing severe muscle spasms. Muscle spasms can be so severe that they tear the muscles or cause compression fractures (when one bone presses against another, causing the bone to break) of the vertebrae. Tetanus typically begins with mild spasms in the jaw muscles (trismus), neck muscles and facial muscles. Stiffness quickly develops in the chest, back, abdominal muscles and sometimes the laryngeal muscles (which subsequently causes difficulty breathing). Muscular seizures (tetany) cause sudden, powerful and painful contractions of muscles. Symptoms usually occur anywhere from five days to 15 weeks after infection. Without treatment, one out of three people die from tetanus infections. Tetanus treatment may include tetanus immune globulin, antibiotics (like penicillin, clindamycin, erythromycin or metronidazole) and muscle relaxers (like diazepam).

Diptheria is an infectious disease caused by the bacteria Corynebacterium diphtheriae. The disease is transmitted through respiratory droplets of an infected person or someone who carries the bacteria but has no symptoms. The disease can also be transmitted via contaminated objects or foods. Common symptoms include sore throat, painful swallowing, hoarseness, drooling, fever, chills, bloody and/or watery drainage from the nose, croup-like cough, difficulty breathing, rapid breathing, bluish coloration of the skin and skin lesions. Symptoms typically appear two to five days after exposure to the bacteria. About 10% of diphtheria patients die. Treatment typically includes intravenous fluids, oxygen and insertion of a breathing tube.

VACCINATIONS RECOMMENDED FOR SPECIFIC HIV PATIENTS

Hepatitis A virus (HAV): The hepatitis A virus (HAV) vaccine is recommended for HIV-infected patients who are healthcare workers, men who have sex with men, injection drug users, hemophiliacs, people with chronic liver disease (including chronic hepatitis B or C) or for people who are traveling to regions of the world where hepatitis is prevalent. Patients receive two shots over 12 to 18 months.

Hepatitis A is a highly contagious liver infection that is caused by the hepatitis A virus (HAV). Although not usually as serious as other types of viral hepatitis, hepatitis A causes inflammation of the liver that may affect the liver's ability to function. The liver is primarily responsible for filtering most of the nutrients that are absorbed in the intestines, as well as removing drugs, alcohol and other harmful substances from the bloodstream. Symptoms of liver malfunctioning may include abdominal pain (especially near the liver), dark urine, jaundice (yellowing of the skin and eyes) and blood in the urine. In rare cases, hepatitis A can be life threatening and cause liver failure.

Hepatitis A/Hepatitis B combined vaccine (Twinrix©): The hepatitis A/hepatitis B combination vaccine (Twinrix©) is recommended for HIV patients who require both HAV and HBV immunization. Patients receive three shots over a one-year period. The effects of the vaccine typically last about four years.

Haemophilus influenzae type B: The HiB (Haemophilus influenzae type B) vaccine is used to prevent bacterial meningitis that is caused by H. influenza type B. HIV-positive adults and their healthcare providers should discuss whether the Haemophilus influenzae immunization is needed. The patient receives one shot during his/her lifetime.

H. influenzae is a widespread bacteria that is present in about 75% of people. However, the bacteria do not easily infect individuals who have healthy immune systems. Therefore, it is considered an opportunistic infection.

Meningococcal: The meningococcal vaccine is administered to prevent bacterial meningitis that is caused by Neisseria meningitides. The vaccine is recommended for HIV-infected patients who are college students, military recruits or traveling to developing countries. The patient receives one shot during his/her lifetime.

Meningitis is a bacterial infection of the cerebral spinal fluid (CSF), which surrounds and protects the brain and spinal cord. Common symptoms include fever and chills, severe headache, stiff neck, sensitivity to light, mental status changes and nausea and vomiting. Some patients suffer long-term complications, including hearing loss, mental retardation, paralysis and seizures, even after treatment. Advanced bacterial meningitis (meningitis that has not been diagnosed during the early stages) can cause brain damage, coma and death.

VACCINATIONS NOT RECOMMENDED FOR HIV PATIENTS

Anthrax, smallpox, varicella (chicken pox) and varicella-zoster (shingles) vaccines are not recommended for HIV patients. The currently available smallpox and varicella vaccines are live viral vaccines, which have been reported to cause infections in the vaccine recipient and may even sometimes infect those who come into close contact with a recently vaccinated individual. While this is rare, it occurs most often in individuals who have weakened immune systems. Therefore, with the exception of the MMR vaccine, live vaccines are not recommended for people with HIV. The MMR vaccine is administered in HIV patients because the health benefits outweigh the potential risks of vaccination. Although the currently licensed anthrax vaccine is not a live vaccine, the Advisory Committee on Immunization Practices does not recommend routine anthrax vaccination because anthrax does not pose an increased risk for HIV patients.

AUTHOR INFORMATION

This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

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• AIDSinfo. http://aidsinfo.nih.gov. Accessed March 28, 2007.
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• National Vaccine Information Center. www.909shot.com. Accessed March 28, 2007.
• Natural Standard: The Authority on Integrative Medicine. www.naturalstandard.com. Copyright © 2008. Accessed March 28, 2007.