Pneumococcal vaccine for HIV patients

BMJ 1995; 311 doi: http://dx.doi.org/10.1136/bmj.311.7001.387b (Published 05 August 1995) Cite this as: BMJ 1995;311:387
  1. Paula McDonald, Senior registrar in public health medicine,
  2. Lorraine Lighton, Pharmaceutical adviser,
  3. Ros Anderson
  1. Consultant in communicable disease control West Pennine Health Authority, Oldham OL1 2PL
  2. Tameside Family Health Services Authority, Hyde, Cheshire SK14 1NG

    Patients with HIV infection should be immunised…

    EDITOR,--We were dismayed by the article of A Jain and colleagues, which was published just as we were about to start a pneumococcal vaccine campaign in Tameside. We do not agree with the conclusions of Jain and colleagues, and we do not see how they arrived at them from the evidence they cite.

    We agree that the Department of Health's policy is not being well implemented, but this is not specific to HIV infection. Failure to vaccinate has many causes, including lack of ownership of responsibility for implementing the policy, the low status and difficulty in identifying the target groups, and, until recently, limited supplies of the vaccine in the United Kingdom.

    Jain and colleagues first suggest that a policy of early vaccination in HIV infection is reasonable. Later, they advise that vaccinating some or all HIV positive patients is illogical. Which piece of advice do they wish us to follow?

    They seem to call for a (randomised controlled?) large clinical trial of vaccine efficacy in HIV positive patients. At this stage a more ethical (and cheaper) approach would be to carry out a retrospective cohort analysis.

    They also suggest that “data from trials suggest that the vaccine works in healthy but not immunocompromised people.”1 The vaccine works less well in immunocompromised people, but it does offer some protection.2 3 Their comment that those who will benefit the least are being vaccinated is illogical. The desired end point of immunisation is prevention of infections, not good antibody values. There is more health gain in providing partial protection to patients whose risk of infection may be up to 600 times increased4 than there is in providing good protection to someone at low risk of infection.

    The vaccine has not been shown to perform worse than the very low efficacy and shortened duration at which Rose et al estimated that it was still cost effective.5 We will continue to advise general practitioners in Tameside to vaccinate patients at all stages of HIV disease.