Immunization in patients with HIV infection: are practical recommendations possible?

The purpose of this article is to review immunization recommendations for HIV-infected individuals in resource-constrained countries, particularly in sub-Saharan Africa. Recent evidence suggests that HIV-infected children are at risk for low immunization coverage in sub-Saharan Africa. Routine immunization is recommended for these children. In comparison with immunocompetent children, recommendations for live-attenuated vaccines differ in HIV-infected children. However, limited laboratory capacity to diagnose HIV infection amongst young children prevents the implementation of these HIV-specific guidelines in resource-constrained countries. Re-immunization has been the focus of recent research in high- and middle-income countries. Findings show that children established on highly active antiretroviral therapy have suboptimal vaccine-specific immunity and may benefit from re-immunization. Before re-immunization guidelines can be formulated for resource-constrained countries, several questions should be addressed, including whether all HIV-infected children will benefit from routine re-immunization and what optimal number of vaccine doses should be administered. Pneumococcal and influenza infections are important causes of morbidity and mortality amongst HIV-infected individuals. There is compelling evidence showing that pneumococcal conjugate vaccines will protect HIV-infected and uninfected children against invasive infection. Pneumococcal conjugate vaccines should be prioritized for introduction in countries with high HIV prevalence. Although, annual influenza immunization is recommended for HIV-infected individuals, the effectiveness in Africa remains unclear. In conclusion, this brief overview has identified several limitations of current immunization policy and practice for HIV-infected individuals living in resource-constrained countries.