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Improve the lives of people with HIV by prevention of pneumococcal disease
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Pneumococcal disease causes substantial morbidity and mortality in people with HIV.
Although adherence to antiretroviral therapy regimens diminishes the risk for invasive pneumococcal infections (eg, bacteremia, meningitis) among people with AIDS in the United States, the risk of pneumococcal disease remains about 35-fold higher in this population compared with age-matched HIV-uninfected Americans.
Thomas M. File Jr.
Furthermore, in the United States, the overall incidence of pneumococcal disease in this risk group has not been diminished by the herd immunity effects from childhood pneumococcal conjugate vaccination to the same degree that has been observed in other adults. Thus, complementary efforts to reduce the risk of pneumococcal disease are needed to improve the quality of life for people who have HIV.
The CDC recommends pneumococcal polysaccharide vaccine (PPSV) for all adults who have HIV, followed by revaccination after 5 years, because of waning immunity in this high-risk group. Immunization is important not only because of increased risk of pneumococcal disease in people who have HIV but also because treatment is complicated by an increased incidence of antibiotic-resistant invasive disease in this population.
Surveys show that pneumococcal vaccination rates are not optimal in U.S. adults with risk factors. The highest documented U.S. pneumococcal vaccination rate is 67% in people who are 65 years and older. The rates are much lower for working-age adults. In fact, in a large national survey, supported in part by CDC, only one in four adults aged 19 to 64 years with underlying “high-risk” conditions (eg, lymphoma, leukemia, diabetes, failing kidney function, splenectomy/functional asplenia) reported having ever received pneumococcal vaccine. Although HIV infection was not studied as a risk factor, it seems reasonable to assume that vaccination coverage rates in those who have HIV are also suboptimal.
Vaccine effectiveness
Questions of vaccine effectiveness may contribute to vaccination decisions.
Protection against invasive illness has been demonstrated in numerous studies of PPSV in people who have HIV, although their immunologic response may not be comparable to that of immunocompetent individuals.
A recent observational study in Spain showed that PPSV-vaccinated HIV-positive adults hospitalized with invasive pneumococcal disease were less likely than unvaccinated patients to die or be admitted to the ICU.
However, in a randomized, placebo-controlled study conducted in Uganda, there was an increased incidence of pneumonia from all causes and no demonstrated protection against invasive pneumococcal infection in those vaccinated. It is important to acknowledge the results of the Ugandan study but also to recognize that there are major differences between the settings that complicate the extrapolation of results from Uganda to the United States. For example, many fewer individuals were on ART, and other host and environmental factors that may affect the risk of pneumococcal disease are also likely different in the two settings.
The use of ART and CD4 >200 cells in people who have HIV have been shown to be associated with the immune response to and observed effectiveness of pneumococcal vaccination.
Because the use of ART in the United States is high among those who have HIV — for whom it is appropriate — it seems reasonable to assume that PPSV would confer at least some protection against invasive pneumococcal disease.
Given the body of evidence, HIV specialists strongly encourage pneumococcal vaccination as a routine component of management plans to those infected with HIV to help protect them from this potentially fatal illness. However, lower ART uptake in certain subgroups, including the uninsured or underinsured, should certainly be considered when deciding whether to vaccinate those infected with HIV, even in the United States.
Preventive health interventions
With more than 1 million Americans living with HIV and significant numbers of new infections each year, the HIV epidemic continues to be a major challenge for U.S. health care providers. Dramatically improved prognoses followed the introduction of ART, now in widespread use in the United States (about 85% coverage), and treatment standards have led to prolonged survival among people living with HIV. This has increased the focus on the need for primary health care, with an emphasis on prevention, as reflected in comprehensive treatment guidelines published recently by a working group of the HIV Medicine Association of the Infectious Diseases Society of America. A cornerstone of this guidance rests on preventive health interventions and, specifically, immunizations against preventable infectious disease, such as pneumococcal infection.
For now, this includes vaccination with PPSV. In the future, pneumococcal conjugate vaccines, or later vaccines based on noncapsular protein antigens, may play a greater role in prevention of pneumococcal disease in adults with HIV.
For example, a recent study of the 7-valent conjugate vaccine for secondary prevention of invasive pneumococcal disease in HIV-infected Malawian adults showed some protection from vaccine-type invasive disease and did not show the kind of increased risk of pneumonia observed in the Ugandan trial with PPSV.
With a 13-valent pneumococcal conjugate vaccine recently licensed by the FDA for infants and children and a 10-valent pneumococcal conjugate vaccine licensed in Canada and nearly 40 other countries, we anticipate better immunogenicity (higher protective antibody levels), prolonged duration of coverage with booster doses and greater effectiveness against pneumonia. Should they also suppress nasopharyngeal carriage, as expected, the use of these vaccines in children may prevent noninvasive pneumococcal disease and reduce bacterial transmission.
Continued research into the development and testing of new pneumococcal vaccines for adults and into the optimal schedules for the use of existing vaccines are required. In the meantime, increased compliance with existing recommendations to vaccinate people who have HIV should be a priority.
All of the authors serve on the National Foundation for Infectious Diseases’ Pneumococcal Disease Advisory Board. Dr. Levine is an associate professor in the department of international health at Johns Hopkins University and an adjunct assistant professor of epidemiology at Emory University. Dr. Rehm is a staff physician at the Cleveland Clinic and is vice chair of the Clinic’s Department of Infectious Disease. Dr. File is chief of the infectious disease service and director of HIV Research at Summa Health System and professor of internal medicine, master teacher, and head of the infectious disease section at the Northeastern Ohio Universities College of Medicine.
For more information:
- Breiman RG. Arch Intern Med. 2000;160(17):2633-2638.
- French N. N Engl J Med. 2010;362(9):812-822.
- Grau I. Arch Intern Med. 2005;165(13):1533-1540.
- Hall HI. JAMA. 2008;300:520-529.
- Heffernan RT. J Infect Dis. 2005;191(12):2038-2045.
- HIV Medicine/IDSA 2009 guidelines for management of HIV+ persons.
- Hung CC. Vaccine. 2004;22(15-16):2006-2012.
- Hung CC. HIV Med. 2009:July 29.
- Peñaranda M. Clin Infect Dis. 2007;45(7):e82-e87.
- Rodriguez-Barradas MC. Clin Infect Dis. 46:1093-1100.