A 38-year-old man comes to the office for a follow-up visit after routine annual laboratory studies showed a positive HIV test. He is currently asymptomatic and has never had an HIV-related illness. The patient believes he acquired the infection through unprotected sexual intercourse. Treatment has not been initiated due to pending antiretroviral drug resistance results. The patient has no other medical issues. He immigrated to the United States 15 years ago and does not know whether he received all of his childhood immunizations. The patient received tetanus-diphtheria-pertussis and hepatitis B vaccines during his previous office visit. Vital signs are within normal limits, and physical examination is unremarkable. CD4 count is 500/mm³ and plasma viral load is 42,000 copies/mm³. Antibody titer testing shows immunity against measles, mumps, and rubella but low titers of antivaricella antibody. Which of the following is the most appropriate recommendation regarding a live varicella vaccine for this patient?

Question

Quizplus · Accepted Answer

The varicella vaccine contains live attenuated virus. Vaccination results in an extremely low virulence infection that poses minimal risk to immunocompetent individuals but significant risk to those who are severely immunocompromised. As such, patients with HIV with CD4 counts <200/mm³ should not receive live attenuated vaccinations (varicella, zoster, measles-mumps-rubella [MMR]). Those with CD4 counts >200/mm³ are immunocompetent enough to clear attenuated infections and should receive varicella and MMR vaccinations if titers are low. All patients with HIV should receive the inactivated vaccines (influenza, tetanus-diphtheria-pertussis) recommended for the general population as well as those recommended specifically for people with HIV (pneumococcal, hepatitis B). (Choices A and D) Varicella vaccination is contraindicated only in HIV patients with CD4 counts <200/mm³ (not all HIV patients). (Choice B) Varicella vaccination is typically given to children in 2 doses (age 12-15 months and 4-6 years). Adults with HIV should receive vaccination if titers are low (and CD4 count >200/mm³). (Choice C) Antiretroviral therapy may raise CD4 counts >200/mm³, allowing patients to receive vaccination. However, antiretroviral therapy is not a prerequisite for vaccination in patients who already have CD4 counts >200/mm³. Educational objective: The varicella vaccine is a live attenuated virus that causes a low virulence infection after inoculation. Patients with HIV with CD4 counts <200/mm³ may have difficulty clearing the attenuated virus and should not receive vaccination. Those with CD4 counts >200/mm³ who have low titers should receive the varicella vaccine. References: Prevention of measles, rubella, congenital rubella syndrome, and mumps, 2013: summary recommendations of the Advisory Committee on Immunization Practices (ACIP). (http://www.ncbi.nlm.nih.gov/pubmed/23760231)

A 38-Year-Old Man Comes to the Office for a Follow-Up