Numerous immunizations are recommended for all persons with HIV, starting with the 13-valent pneumococcal conjugate and 23-valent pneumococcal polysaccharide vaccines, respectively, at least 8 weeks apart; a 23-valent polysaccharide vaccine booster is also recommended after 5 years. Patients who are not already immune or infected with HBV should receive the hepatitis B vaccine series. Influenza, tetanus-diphtheria-pertussis, hepatitis A, and human papillomavirus vaccinations are indicated as for the general population. Measles-mumps-rubella and varicella vaccines can be given as long as the CD4 cell count is greater than 200/µL. Although the recombinant zoster vaccine is considered safe in immunocompromised persons because it does not contain live virus, safety and efficacy data in patients with HIV are not yet available to inform recommendations. The Advisory Committee on Immunization Practices recommends that all persons with HIV infection be vaccinated for meningococcal disease with the quadrivalent meningococcal vaccine, including boosters every 5 years.
Prophylaxis for opportunistic infections depends on the patient's CD4 cell count (Table 65). Before beginning prophylaxis, active infection should be ruled out clinically and with any indicated testing to avoid undertreatment and selection for resistance, especially for tuberculosis and disseminated Mycobacterium avium complex.