Viremic – Cases in HIV

Announcer:
Welcome to Viremic–Cases in HIV, hosted by Dr. Eileen Scully and Dr. Christopher Hoffmann, both HIV specialists at Johns Hopkins, who explore quandaries in adult HIV care. Each case discussion includes medical history and diagnoses, challenges in care and treatment, and key evidence and guidelines that inform clinical decision making.

Cases are presented as a composite from the hosts’ clinical practice, with all identifying details removed to protect the privacy of patients. Case discussions are for informational purposes only and not offered as medical or clinical practice advice for patients or clinicians. Any mention of specific medications or commercially available products is a description of use only, not an endorsement.

Dr. Christopher Hoffmann:
Welcome to Viremic. I’m Chris Hoffman, and I’m joined today by my friend and colleague Eileen Scully. We’re both based in Baltimore at Johns Hopkins.

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Eileen, it’s good to be discussing HIV care with you again today. I’m looking forward to hearing your perspectives on vaccination.

Dr. Eileen Scully:
Chris, it’s great to be here. This is such a relevant and important topic. I’m excited to talk about it.

Chris:
Awesome. We’re going to maybe have a slightly different format, but still case-based. Given the long list of vaccinations that are important to provide, we won’t go through all of them, but perhaps just highlight our favorite vaccines, understanding that all vaccines that are recommended are important.

I’m going to start this with a case that I’ve seen multiple times, and that’s a patient who’s transferring care to me. I have very limited or no access to medical records. Often the medical record that’s hardest to access is vaccination history, especially for patients transferring in from other states. This patient was a 51-year-old gay man diagnosed with HIV in the early 2000s. He was started on antiretroviral therapy in about 2007; his CD4 count was in the 500s. He’s done very well on antiretroviral therapy, maintaining an undetectable viral load on several different regimens. He’s currently taking the combination formulation of dolutegravir and lamivudine.

He hasn’t had any opportunistic illnesses. He does have some other comorbidities, including hypertension, which is controlled with just one agent, and he has pre-diabetes that he’s working on with adjusting his diet. He’s on a statin for cardiovascular risk reduction. He’s a lifetime non-smoker.

He is sexually active with his husband, but it’s an open relationship and occasionally has sex with other men in his social circle.

He’s up to date on routine primary care screening, including colon cancer screening with colonoscopy and anal cancer screening with anal digital rectal exam and Pap smear. The Pap had normal cytology and was negative for high-risk HPV types.

He reports having received several vaccines in the past, including 3 COVID-19 vaccinations and a pneumonia shot some years ago, although he doesn’t remember the exact name of it. He’s unsure of dates or specifics of any other vaccines. Getting his old vaccination record seems impossible. He is open to getting some vaccinations today, but doesn’t want to do too many at once, partly because of side effects and partly because he just doesn’t want to get too many jabs on one day.

So, to start Eileen, how do you discuss vaccines with your patients?

Eileen:
This is such an important part of what we do and especially in the current climate where there’s so much mistrust of the medical system and specifically vaccines. I think we should just call it out directly, so I usually start off by asking people what they understand about vaccines. Then I’ll ask them to give me a little bit of indulgence because in addition to being an infectious disease doctor, I’m also an immunologist—I love thinking about how the immune system works.

Then I’ll just outline what a vaccine does. I’ll say:
“All of us have immune systems, and part of our immune system can actually learn what viruses and bacteria look like, and once we learn what it looks like, the next time we see that same thing, oftentimes we’re better able to fight off that infection. This can happen when you become naturally infected, although a lot of those pathogens have ways to get around that immune response or make it slightly less effective. What we do with vaccines is take a small piece of whatever it is we’re trying to prevent or control, and we just show the immune system. We say, ‘Hey, look for this. If you see this, that’s a problem, and you should do something about it.’ And it hopefully will teach some of our T cells and B cells, get us some antibodies that will recognize that pathogen when we do encounter it as we’re just walking around in the world.”

There’s a lot of mystery about what vaccines do and what they’re inducing. I think breaking it down to what it really is, which is just an education of the immune system so that it’s better able to respond next time, can help demystify it a little bit.

Then also I will say:
“You may have heard a lot about adjuvants or the ways that we get vaccine components to work. Those are things that you are also exposed to when you’re exposed to an infection. We’ve just purified them and instead of having you respond to all these different components, we’re only using the ones that are absolutely necessary. And hopefully the result of that is something that’s actually getting you the education for the immune system that you need, but way more safely than being exposed to everything all at once.”

And then I’ll ask if they have other specific questions, if they’ve heard stories, if they personally have had a bad experience with a vaccine or someone in their family has. Of course, I don’t have this whole conversation and people are like, “Okay, great, tell me the ones I’m due for,” but if people express hesitation, I like to lean into that because I think then all of the conversations about the ones we recommend and why are just much more informed.

Chris, how do you approach it?

Chris:
Well, first, I love your approach—educating the patient about vaccines educating the immune system. So, I’ll keep that for future use in talking to patients.

I often start with their experience with prior vaccinations and how they perceive vaccines to approach patients depending on where they’re coming from. I certainly have some patients who are, you know, “What’s the next vaccine for me? Please give it to me,” and some others who feel like vaccines aren’t for them and they never get the flu during flu season except the one year that they got the vaccine and they immediately got the flu. And then a few others who feel like there’s a mandate, especially during the COVID period, to get lots of vaccines, and they really want an independent choice. Each group needs to be addressed differently. I think the last, in a way, is easiest, because when I give them the choice and explain the risks and benefits and the purpose of the vaccine, often there’s willingness to discuss and then willingness to select the right vaccines for that visit.

Eileen:
Chris, I’ll add one other thing—in my clinical practice, I’ve noticed that we do have wonderful medical assistants who room our patients, and they routinely offer vaccines. Their uptake rate of vaccines is very low compared to mine. So, I would encourage anybody who’s listening that if they are having some of their patient care team do a pre-screening and a pre-questionnaire with patients about whether or not they would like any vaccinations on the day of their visit, even if the patient declines, it’s often worth a conversation because people may say no in a offhand way, but with a more engaged conversation, may be much more open.

Chris:
I agree, and I think we probably both have had visits in which the patient almost starts the visit saying, “I don’t want whatever the vaccine is,” and by the end they’re saying, “When are you going to administer that vaccine for me?” Education can be so helpful.

If we shift now to my patient, 51-year-old man living with HIV, I realize that each vaccine has an important role, but for this discussion, I thought we could select some of our favorites that hopefully will be applicable to this gentleman, but not necessarily. Perhaps we can alternate with favorites, selecting what we like, but not selecting one that’s already been presented.

Starting with you, Eileen, what’s your favorite vaccine overall, or a favorite to start with a patient who has an unclear vaccination history, such as mine?

Eileen:
This is a great question because, you know, we love all of them, but I’m going to start with one that, I’m sure some people will disagree with, but I’m going to start off with hepatitis B. Why would the hep B vaccine be my favorite? Well, I think again, when talking about vaccines, one of the things I find most effective in communicating with patients is to put it in the context of what you’re actually trying to prevent.

So, before I talk about the vaccine, let’s briefly think about hepatitis B itself. Too often we discuss the vaccine characteristics, what the additives are, does it work, the side effects, but sometimes forget the point of the vaccine. In this case, hepatitis B we know to be a highly transmissible virus, much easier to acquire than either HIV or hep C. We also know that the outcome of transmission can either be ongoing chronic infection or can lead to the development of an effective immune response with a resolved or occult hepatitis B status but not really totally eliminating hepatitis B.

This is not a brief respiratory virus. It is one that needs to be contended with in the long term over a lifespan. Hepatitis B infection is associated with the risk of chronic liver disease and hepatocellular carcinoma, and these risks are enhanced by co-infection with HIV, making it even more important to prevent acquisition if at all possible.

Finally, hepatitis B is treated by some but not all of our antiretrovirals, and this makes it an important factor when we’re considering treatment switches and new options that don’t include our primary hepatitis B-directed drug, tenofovir.

In general, for people with HIV, preventing acquisition and ensuring immunity can ease up several layers of concern about ART management and also about chronic liver disease. If you’ve now accepted that hepatitis B is important and also not that hard to get, I’ll then move on to saying that many of our currently available vaccines are extremely safe, well-tolerated and effective. For many years, we’ve had hepatitis B vaccine formulations, notably Engerix-B, which is widely available, that have up to 70% efficacy in people with HIV, increased to about 75% when you use a double dosing protocol.

This efficacy is modified by HIV status. If you were viremic, had a low CD4 count or a low CD4 nadir and persistent low CD4 count, that can alter how well the vaccine will work. But it does actually work for the majority of people.

In recent years, we’ve done even better. We now have the CpG- or TLR-adjuvanted Heplisav vaccine that increases our probability of success. This was studied in the BEe-HIVe trial done in the ACTG, where investigators looked at individuals who had previously not responded well to the older formulations of hepatitis B vaccination, so hep B vaccine non-responders. They found that 93% of those people mounted an effective protective response to a 2-dose vaccine series with the new Heplisav vaccine. This went up to 99% if you gave 3 doses, as compared to only 80% of those who got another 3 doses of Engerix-B. Overall, we have a vaccine that’s well tolerated. Adverse events were generally injection site pain, headache, fatigue, malaise, myalgia—the kinds of things we often see after vaccination, but not that severe. It is very effective, and once you have a hepatitis B surface antibody titre, it provides really good protection against acquisition. It also provides an added layer of comfort if we think there’s a possibility that you may have previously been exposed to hepatitis B in an isolated hepatitis B core antibody status.

I won’t spend too much more time on hepatitis B. I think we’ll have to have a whole discussion about that, but I do think this is a safe, effective, and really important vaccine. How about you, Chris? Who are you going to draft first from the vaccine bench?

Chris:
Well, can I give a shout out to hep B vaccine, especially the Heplisav first? The point you raise about tenofovir being prophylaxis against hepatitis B is so important as we’re moving to regimens that don’t include tenofovir, such as long-acting antiretroviral regimens with cab/rilpivirine or with dolutegravir/lamivudine, such as this gentleman is on.

In addition, specifically for him, should his blood work show that he is not immune to hepatitis B or living with chronic hepatitis B, given that he has multiple sexual partners, he’s certainly at increased risk for acquisition of hepatitis B. I could not agree more that if we can give a vaccine to prevent a disease that can cause acute severe illness and chronic lifelong infection, we should do that every time.

My top choice is the Prevnar 20 vaccine. There are a few reasons for that. One way I think about vaccines is severe, potentially life-threatening illness that may be very rare, and diseases that fit in that category include meningococcal meningitis, for which we have a number of vaccines. Then there are more common diseases that have a whole wide spectrum of illness, such as pneumococcal pneumonia, which can be fatal, but also can be more mild illness. And then there are diseases that are generally not fatal, but can be severe, debilitating, and cause long-term morbidity, such as zoster.

Prevnar-20 is my top pick. It’s highly effective. Like Heplisav, the new vaccine for hepatitis B, Prevnar-20 has really changed prevention of pneumococcal disease and pneumococcal pneumonia and invasive pneumococcal disease, switching an approach from a relatively complex algorithm that I believe led to under-vaccination for pneumococcal disease to higher uptake now. The previous algorithm included the Pneumovax 23 as well as the PCV vaccines. The current recommendation can include both of those, but essentially, if you give one shot of the PCV or Prevnar 20, that is sufficient for preventing pneumococcal disease by a considerable amount, up to 60 or 70% and reducing the severity of disease.

Fortunately, we don’t see pneumococcal disease every day, but in people with HIV, even those with an undetectable viral load, the risk of pneumococcal disease is greater than in similar aged people without HIV. The morbidity and mortality for hospitalization remains high—10 to 20% 60-day mortality after hospitalization for pneumococcal disease. Any way to prevent that is something I want to go for.

The last point about the Prevnar 20 is that there are other Prevnar formulations. There are the conjugated pneumococcal vaccines, 13, 15, 20, and 21, each containing protection against different stereotypes. I think it’s worth noting specifically with the 20 and 21 that they protect against different serotypes, and specifically, the conjugated pneumococcal vaccine 20 protects against serotype 4, which the 21 does not. Serotype 4 is increased in a number of Western states in the United States. It’s important to be aware where you’re using the vaccine or where your patient may be spending a lot of time in terms of selecting 20 versus 21.

It just happens that we tend to have 20 available in my clinical practice, so that’s what we give. But probably I would prefer that over the 21 anyway. So, for both the innovation of the conjugated pneumococcal vaccine 20 in terms of being a single vaccine for invasive pneumococcal disease and pneumococcal pneumonia, as well as the ability to prevent severe illness from pneumococcal disease, that’s my top choice.

Eileen:
I love that discussion, and I will say that “the pneumococcus,” as I was taught to refer to it back in my days as a fellow, is something to be feared and respected. Anything we can do to boost immunity to it is likely to help overall in outcomes. People should remember that the most common cause of pneumonia in people with advanced AIDS is still standard bacterial pneumonia, and of those pathogens, the pneumococcus is one of the most common and one that can have the most severe and invasive complications.

The degree of protection varies by the type of vaccine, the local serotypes, and the population. But even when there is a modest impact on pneumonia, these vaccines are in general effective against bacteremic and invasive pneumococcal disease, which is something that we need to prevent to reduce mortality.

I have a brain block in recalling all of the different pneumococcal vaccinations. For those who need a quicker summary, the PCV 20 and 21 are “one-and-done.” You don’t need to do the series that would require the PPSV 23 after the lower PCV, but you should just look it up and know that there are different types of vaccines and you want to get the one that has the broadest level of protection. I’ll also acknowledge that some providers don’t have the maximal choice, and it’s good to know that the other older formulations may require 2 shots, but you can often get up to a similar level of valency for your protection.

Chris:
Great points. The algorithm is there; [it’s] very hard to remember each point of it, but with any of the lower valent vaccines, such as the PVCV-15, you’d also need to use the Pneumovax either 1 year before or 1 year after, but look it up to double-check.

Eileen:
You’ve taken one of my favorites, but don’t worry, I’ve got more. I will next say MMR. This is a controversial choice, especially because we’re talking about someone who’s 51 years old, and there could be some questions about whether or not it would be necessary. But I think I’ll use this opportunity to give this concept of vaccination for measles bumps and rubella a little bit of airtime.

Measles, as we’ve all heard, either passively or actively through looking at the numbers, is on the rise in the United States. The most recent CDC data as of May 14th of 2026 had 1,893 confirmed cases in 2026 and 27 new outbreaks in 2026 [see CDC: Measles Cases and Outbreaks https://www.cdc.gov/measles/data-research/index.html]. For reference, in 2024, there were 285 cases total for the whole year. We’ve been in an outbreak since 2025 when we saw 2,288 cases, but we’re on track to exceed that based on the 2026 numbers so far. What this means is not only that a large proportion of these cases have occurred in children under 5 (about a quarter of the cases) and children and adolescents ranging up to 19 years account for 60 to 70% of the cases.

You may ask why I’m thinking about this for a 51-year-old. We have been lulled into safety by very high rates of total vaccination in the population so even if there were people who had missed vaccines, they were generally protected because the community was largely vaccinated. As we move into an era where there are more cases and more potential exposure events, it becomes more important for us to think about whether or not the individual in front of us is potentially at risk for some of these diseases that have fortunately become so rare.

The guidelines are if you’re born prior to 1957, which would not be true for our patient, then you’re presumed to have had natural exposure. If you have documented vaccination, then you’re presumed to have immunity, or you can have documented immunity based on your serostatus, meaning you check antibodies and you note that they are in fact positive. In the DHHS guidelines for this at least, they say documented vaccination or seropositivity. This is a nod to the fact that in some serosurveys, people with HIV don’t necessarily maintain positivity for all of these vaccine components throughout their lifetime. This will become something that we learn more about, or maybe we’re lucky enough not to learn more about it if the measles outbreaks are contained. But as we think about who needs this and when to consider this vaccine, serostatus can be a nice confirmation. It wasn’t previously required if you had documented vaccination, and we’ll have to see how that holds as the situation evolves.

The other reason why I brought this up is because MMR is actually contraindicated in people with a CD4 count <200. We should be aware as HIV providers that there are, in fact, HIV-specific recommendations. The reason for this contraindication is cases of fatal vaccine-induced pneumonitis. I’m going to pause there because I think we very rarely think of fatal outcomes as being related to vaccines. It’s important that we acknowledge that those cases were reported and it is possible that in people with advanced immunocompromise, you can see bad outcomes from vaccination. For this reason, people with non-suppressed HIV and CD4 counts that are low are not recommended to receive the vaccine.

This patient has plenty of CD4 T cells, has been suppressed for a very long time. If there was a possibility that he had missed childhood vaccinations, we could certainly administer it to him with good safety record. That has been well-documented when you are immune reconstituted above 200 and you have a good suppression of your viral load, the MMR is safe and effective. I brought it up because I do think this vaccine has saved many, many lives over time, maybe not specifically in people with HIV, but people with HIV have definitely benefited from the herd immunity associated with large scale vaccination against measles, mumps, and rubella. It’s something we should have in the back of our heads as our patients are at risk of higher degrees of disease severity. Are they exposed? And for some of them, with CD4 counts that are reconstituted, they would be candidates to receive this vaccine if they did not otherwise have demonstrated immunity. So maybe slightly controversial. I don’t know. What do you think, Chris?

Chris:
I do have a few questions. First, I wanted to emphasize the point you brought up of live vaccines and a CD4 count <200. Fortunately, my patient’s CD4 count is higher, but the MMR, varicella, and then some less used vaccines, such as the live attenuated typhoid, yellow fever, all are live vaccines and are not recommended for people with a CD4 <200.

The question I have for you, and this has come up for me several times—patients ask if they should get the MMR or ask if they should have their titres checked At various times I’ve given various answers, but what’s your answer, Eileen?

Eileen:
This is a great question, and to be honest, I think we need more data. As I mentioned, there’s earlier studies that have shown that people with HIV don’t retain antibodies potentially, so if we checked everybody, we might identify a lot of people who might fall below the detectable levels of antibodies. Then you could go into the algorithm of, well, if you were positive for mumps and rubella, which does sometimes happen, and negative for measles, we can assume vaccination. That’s probably true. Do we know if that’s as protective? We don’t actually know, or at least I don’t believe that we have great data to know whether or not that’s as protective if your antibody has waned below detection. But even my other favorite vaccine, hepatitis B, there’s some controversy about whether or not we should be boosting levels to detectable or titres that are considered protective, or whether that boosting would happen naturally upon encounter with the pathogen.

I use a very patient-specific framework for that. What’s the patient’s level of risk tolerance? What is their health care trajectory? Have they always been in what I would consider good general health care, attending school, doing all the things that would normally lead to verification of vaccination? And do they have other immuno-compromising or other conditions that might increase their vulnerability? And then consider checking a titre. I would also check for mumps and rubella in that same check to see whether I could document that they’d at least been exposed to the vaccine products.

Chris:
Very good. So, it sounds like sometimes I get it right. My next choice will be the human papilloma virus vaccine. I refer you to a podcast I did with Dr. Bruce Hirsch on anal cancer as the grounding for that.

In terms of severe, lifelong, and potentially fatal illnesses, squamous cell carcinoma from human papillomavirus, anal cancer, cervical cancer, or oropharyngeal cancer are preventable and can be very morbid as well as reduce life expectancy should those develop. HPV vaccine can prevent cervical cancer, appears to do a good job of preventing high-grade anal dysplasia. I imagine, although I’m unaware of studies looking at tonsillar cancer related to HPV, but I imagine it would reduce all of those. And there’s some beautiful examples, including in Australia, where mass HPV vaccination has almost eliminated cervical cancer among women. Extrapolating from that, I think we can expect a similar impact on anal cancer or squamous cell anal cancer, as well as HPV-related tonsillar cancer, and seeing that eliminated would be wonderful. Managing any of those conditions in my patients is a challenge, seeing what they go through. This is a vaccine that can prevent it, which is why it’s number 2 on my list.

Eileen:
Chris, can you comment a little bit on considering this vaccination in someone who’s 51 as opposed to the younger populations for which it was initially studied?

Chris:
Yeah, thanks for bringing that up, Eileen. Initial studies were on young women. Since that time, the age range for recommendation has expanded, and currently it is recommended for people living with HIV aged 18 to 26, with a consideration of vaccination for ages 27 to 45. My patient falls out of that range, although I will note that on his Pap smears, no high-risk HPV has been identified, but he is at risk for potential exposure to HPV through his sexual contact and multiple sexual partners. Whether he would be the ideal candidate, probably not. A young individual with HIV may get longer-term benefit. What we do know is that based on his Pap data, he does not have an ongoing infection with a cancer-causing, high-risk HPV type; and he could very well benefit from HPV vaccination. But Eileen, how do you counsel older individuals regarding HPV vaccination.

Eileen:
It’s a challenging conversation. It’s not currently FDA-labeled for use in people over 45, and that becomes a barrier primarily related to insurance coverage because it’s using something outside of its indication according to the FDA, which just means they often won’t cover it. I think that the data that doesn’t support it in older populations may be somewhat limited by, in general, it’s easier to document acquisition in younger groups who may be more sexually active and may be at risk more frequently. That doesn’t show that it wouldn’t work in the older age group. I share your general feeling that it’s possible that this might allow some immune protection since his sexual practices, as you outlined them, would suggest that he is at risk. Then it’s a very reasonable conversation to have with the additional discussion that this isn’t outside the recommended age range and that has implications for the fact that we don’t have direct evidence to support it, but also that insurance may in fact not cover it.

Chris:
Very good points. I think something like this is shared decision-making, and if insurance is going to be a barrier, that is also an important point. I definitely try to prioritize the HPV vaccine among younger individuals.

But back to you, Eileen, what is number 3 on your list?

Eileen:
For our probably last vaccine to talk about today, I thought I would draft the Zoster vaccine. I think anyone who’s ever experienced Zoster would probably pretty clearly state that they would not like to do that again. Unfortunately, for some people, neuropathic pain can recur in the same distribution. We’ve all seen the TV commercials where even professional football players complain at length about how painful shingles can be.

The Shingrix vaccine, which is recommended for all adults with HIV over the age of 18, which is a difference from the population-based recommendation of over, greater than, or equal to age 50, is an important vaccine to offer. The response is generally better when people are virologically suppressed on ART and with a CD4 count >200, which for our patient, would be true. As a 51-year-old, he’s already ticked into the category of actually benefiting from it even without HIV, so I would definitely discuss this with him sooner rather than later.

There are 2 other things I’d say about Shingrix. While it is quite effective in preventing the reemergence of VZV in the form of shingles, it does have a lot of what we call “reactogenicity,” which is a fancy way of saying it makes you feel pretty bad after you take the vaccine for many people. I directly counsel people about this; I find that being open about potential vaccine side effects is a key, not only for the patient returning to your care, period, but also for them ever accepting a vaccine recommendation in the future. I will ask people if they had a bad reaction to the COVID vaccine, and I will say, “This is similar to that, and for some people, it’s a bit worse.” I often will say things like, “Perhaps you should plan to get it on a Friday, knowing that you don’t have to work on Saturday or whatever your day off of the week is, and you can take some Tylenol if you feel quite bad.” But I do think it’s important to counsel people that they may feel not great.

And then the other sort of literature that I would point people to is this emerging story that it’s possible that vaccination against VZV may attenuate your risk of dementia over time. I will say that although there’s been some high-profile epidemiologic studies, the mechanisms are not clear and we can’t definitively say this, but it’s definitely something that I’m thinking about as I get a little bit older and preventing dementia seems like a really nice thing to do.

We’ll have to watch that and see if that ends up being borne out to be correct or one of those correlations without causation. How do you feel about the zoster vaccine?

Chris:
I think it’s so important, and I do exactly as you do. I counsel patients that they may get a reaction, flu-like illness, the following day that may last 24 to 48 hours. I am intrigued by the prevention of dementia and hope it does, because I’ve gotten my Shingrix.

It’s certainly a vaccine I prioritize. It is 2 shots, which is sometimes harder to get a patient to get than 1 shot, especially if they have that reaction to the first shot. Given that Zoster can be both very debilitating in the short term and can lead to long-term neuropathic sequelae that can be prevented by the vaccine, it’s another one that I love and prioritize.

Eileen:
I’m going to toss it back to you to finish this. We have this gentleman with us. We’ve talked about a few vaccines that we might like, and granted, my vaccine recommendations, both the HepB and the MMR, could be assessed with lab testing first, whether or not you even need them. But what would you prioritize giving to this patient who presents to you? Let’s pretend that it’s spring, not the high time of respiratory viral season.

Chris:
Good point. It would have been very easy for me to put influenza as my top choice. I chose to not do that just to talk about another vaccine, and I’m glad that you’re telling me it’s not peak respiratory virus season. From these vaccines, if he is not immune to hepatitis B, I would say I would prioritize that, but we’ll get the bloodwork and find out. I think in terms of the MMR, depending on his potential epi risk factors would want to see whether he has immunity.

Then in terms of the remaining vaccines we talked about, often I encourage initially getting the pneumococcal vaccine with the conjugated 20-valent vaccine and the shingles vaccine. That is often what I start with, and I think what I would start with for this gentleman. I would also discuss squamous cell cancer risk in talking about anal pap smear testing, which he’s had and was negative, but also prevention and the possibility of using a vaccine but understanding that the FDA labeling is only through the age of 45. Hopefully, he’ll be amenable to that, and we’ll look forward to a future with preventable diseases effectively prevented.

This has been a wonderful discussion. Eileen, very much enjoy learning from you and this time with your immunological background, bringing in additional interesting points.

Eileen:
Well, thank you, Chris. I always learn from you. My mind is actually full of other vaccines we didn’t get a chance to talk about, like Mpox and lots of other things. I think the closing thought I would have is that we have an embarrassment of riches in terms of what we can offer people for vaccines and. I don’t want anyone to feel like they have to memorize it all. There are great resources, which we will have links to, where you can look at what is recommended for every individual at every stage of HIV disease, at every stage of life, and we can offer all of these beautiful preventive things to people as they are indicated.

Chris:
Wonderful points. We will have links in our show note to various references, including the HIVguidelines.org, which has a list of vaccines and other links. In closing, I would say that although these vaccines are highly effective, reduce morbidity, reduce mortality, even some of the most used vaccines, such as the pneumococcal vaccine, reaches less than 50% of people with HIV in the United States. So as providers, we have an opportunity to do better by our patients and prevent morbidity.

In closing, to our listeners, thanks so much for joining another episode of Viremic. Please send any comments or questions to viremicpodcast@jh.edu. And we’ll be back again in two weeks with a case involving HIV management considerations for low-level liver enzyme elevations. Thanks so much.

Announcer:
Viremic is sponsored by the Clinical Guidelines Program, a collaborative effort of the New York State Department of Health AIDS Institute and the Johns Hopkins University Division of Infectious Diseases.

Visit the program’s website at: HIVguidelines.org.

Viremic’s case discussions are for informational purposes only and not offered as medical or clinical practice advice for patients or clinicians. Any mention of specific medications or commercially available products is a description of use only, not an endorsement

The podcast is produced and edited by Mary Beth Hansen and Brian Hatcher with assistance from Jesse Ciekot and Laura LeBrun Hatcher.