A 46-year-old man with chronic HIV infection comes to the office for a health maintenance visit. The patient just moved into the state for a job with an architecture firm. Currently, he is sexually active with 2 male partners and uses condoms. The patient's immunization records show that he received all childhood immunizations through age 18, and received a meningococcus vaccination as a freshman in college. He also received a vaccination for tetanus-diphtheria-acellular pertussis 3 years ago following a motor vehicle accident. The patient has no history of opportunistic infections. He is on antiretroviral therapy, and his last CD4 count was 670/mm³. Assay for hepatitis B surface antibody (anti-HBs) is positive. In addition to influenza and pneumococcus vaccinations, which of the following vaccines is most appropriate for this patient?

Question

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11ec25c8_d225_c42c_bc81_bd20daa1eac4_MD0003_00 HIV-infected patients with a CD4 count >200/mm³ should receive all the vaccines that an otherwise healthy person requires. They should also receive the pneumococcal conjugate vaccine (PCV13) followed by the pneumococcal polysaccharide vaccine (PPSV23) at least 8 weeks later, again after 5 years, and at age 65. Vaccination for hepatitis A is recommended for adults who are at increased risk of contracting the virus such as men who have sex with men (such as this patient) and travelers to countries where hepatitis A is prevalent (eg, contaminated food or water consumption). It is also recommended for adults who have conditions (eg, chronic liver disease) that increase the risk for severe complications. In the United States, the hepatitis A vaccine became part of routine childhood vaccinations in 2006; it is unlikely that this 42-year-old patient received it as a child. (Choice B) Hepatitis B vaccine is recommended for all patients with HIV who do not have documented immunity to hepatitis B. This patient has a positive serology for hepatitis B surface antibody. (Choice C) Human papillomavirus vaccine is generally administered for patients age 11-26 and is not recommended age >45. (Choice D) Certain live attenuated vaccines (eg, measles-mumps-rubella [MMR]) may be given to patients with HIV who have a CD4 count of >200/mm³. However, this patient has already received his childhood vaccines and does not require MMR. (Choice E) Tetanus-diphtheria-acellular pertussis (Tdap) is recommended as a one-time vaccine for all adults, with revaccination provided to women at each pregnancy. Subsequently, tetanus-diphtheria toxoid (Td) booster is recommended at 10 year intervals, or after 5 years in the event of high-risk trauma. Educational objective: Vaccination for hepatitis A is recommended for adults who are at increased risk of contracting the virus such as men who have sex with men and travelers to countries where hepatitis A is prevalent. It is also recommended for adults who have chronic liver disease. References: Vaccination against sexually transmitted infections. (http://www.ncbi.nlm.nih.gov/pubmed/22143117) Vaccination against viral hepatitis of HIV-1 infected patients (http://www.ncbi.nlm.nih.gov/pubmed/22634451)

A 46-Year-Old Man with Chronic HIV Infection Comes to the Office