Education And Debate

Should patients positive for HIV infection receive pneumococcal vaccine?

BMJ 1995; 310 doi: (Published 22 April 1995) Cite this as: BMJ 1995;310:1060
  1. A Jain, medical studenta,
  2. S Jain, medical studenta,
  3. V Gant, senior lecturer in clinical microbiology and infectionb
  1. a United Medical Schools of Guy's and St Thomas's Hospitals, St Thomas's Campus, London SE1 7EH
  2. b Division of Infection, United Medical Schools of Guy's and St Thomas's Hospitals, St Thomas's Campus, London SE1 7EH
  1. Correspondence to: Dr Gant.
  • Accepted 31 January 1995

Pneumococcal vaccination effectively reduces the incidence of invasive pneumococcal disease in normal subjects. Such invasive pneumococcal disease is 100 times more common in patients with HIV infection than in healthy people, so it seems logical to target this group of patients for vaccination. Few clinics routinely vaccinate patients positive for HIV, despite Department of Health guidelines. This is because of uncertainty about the vaccine's efficacy in HIV disease. There are many reasons to suspect that the vaccine will fail to protect these patients, including the fact that antibodies alone may not be sufficient protection against all serogroups of Pneumococcus and the vaccine works in healthy people but not immunocompromised subjects. Vaccination of HIV positive patients may not be indicated, at least for the time being. The cost of vaccinating such patients in the absence of data showing efficacy may well be less than the cost of a necessarily large and lengthy trial. But the truth must be sought to end current indecision.

Prophylaxis against many opportunistic infections in patients positive for HIV infection has deservedly become routine clinical practice; clinicians continue to be divided on whether it should include pneumococcal vaccination. No consensus exists in the United Kingdom or the United States, each country espousing different policies. The incidence of pneumococcal bacteraemia in people with AIDS is 9.4 per 1000 person years annually—a several hundredfold increase over that in an age matched population without such infection.1 In a study from California five out of 41 (12%) patients with community acquired pneumococcal bacteraemia were subsequently found to be seropositive for HIV; Chirurgi et al suggested that for their community this presentation was common enough to be an indication for HIV testing.2 Mortality from pneumococcal disease in HIV positive patients remains substantial and varies from 5% to 20%; 20% mortality …

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