Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 30-year-old woman is evaluated in follow-up after being recently diagnosed with HIV infection. She is asymptomatic. Medical history is unremarkable, and she takes no medications; she has not yet started antiretroviral therapy. She received all scheduled childhood immunizations.

On physical examination, vital signs are normal. She has shotty cervical lymphadenopathy, but the examination is otherwise unremarkable.

Laboratory studies:

Absolute CD4 cell count	461/µL
HIV viral load	44,874 copies/mL
Hepatitis A IgG antibody	Negative
Hepatitis B surface antibody	Positive
Hepatitis B surface antigen	Negative
Hepatitis C antibody	Negative

Which of the following immunizations should this patient receive today?

A. Hepatitis A vaccine
B. Hepatitis B vaccine
C. Human papillomavirus vaccine
D. Pneumococcal conjugate vaccine
E. Pneumococcal polysaccharide vaccine

MKSAP Answer and Critique

The correct answer is D. Pneumococcal conjugate vaccine.

This patient should receive the 13-valent pneumococcal conjugate vaccine (PCV13) now. Vaccination against Streptococcus pneumoniae is indicated in all persons with HIV infection because of the increased risk of invasive pneumococcal disease. Immunocompromised persons, including those with HIV, should receive PCV13 first, followed by the 23-valent pneumococcal polysaccharide vaccine (PPSV23) at least 8 weeks later, in a “prime-boost” strategy that is used to improve the antibody response to immunization. This recommendation applies regardless of the patient’s CD4 cell count.

HIV infection alone is not an indication to receive hepatitis A vaccination. Hepatitis A vaccination would be indicated if the patient had another risk factor, such as men who have sex with men or other liver disease, including chronic hepatitis B or C virus infection. She does not have hepatitis B or C virus infection, as shown by negative results on laboratory testing, so hepatitis A vaccination is unnecessary at this time.

All patients with HIV should be vaccinated for hepatitis B if not already immune or infected. However, this patient has positivity for hepatitis B surface antibody, demonstrating existing immunity. Therefore, she does not require hepatitis B immunization.

This patient is beyond the recommended age (approximately 11-26 years) for females in the general population to receive human papillomavirus vaccination. This recommendation does not change for patients with HIV infection.

This patient should receive PPSV23, but not until at least 8 weeks after PCV13, so giving it now would be inappropriate. Patients with HIV infection who have received PPSV23 in the past should receive PCV13 followed by another PPSV23 dose at least 8 weeks later.

Key Point

• Immunocompromised persons, including those with HIV, should receive the 13-valent pneumococcal conjugate vaccine first, followed 8 weeks later by the 23-valent pneumococcal polysaccharide vaccine.

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