People living with HIV may need an extra dose of COVID vaccine

people with HIV have an increased risk of breakthrough SARS-CoV-2 infections, according to a new study, and the authors say an additional primary vaccine dose should be considered for anyone living with the disease.

Currently, an additional primary dose given 28 days after a second dose of mRNA vaccines (Moderna or Pfizer) or after the first dose of the Johnson & Johnson (J&J) vaccine is recommended only for people with advanced or untreated HIV .

The Centers for Disease Control and Prevention (CDC) recommends boosters for all adults with or without HIV.

Sally B. Coburn, PhD, MPH, of the Department of Epidemiology at Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, led the study, which was published online today in JAMA network open. In their study, the researchers estimate the risk of breakthrough infections in fully vaccinated adults based on HIV status in the United States.

HIV-positive adults who were fully vaccinated before June 30, 2021 were matched with HIV-free adults with respect to date of full vaccination, age, race/ethnicity and gender. All were followed up to December 31, 2021.

Patients were considered fully vaccinated either 14 days after the second dose of the Pfizer or Moderna vaccines or 14 days after the single dose of the J&J vaccine.

Breakthrough risk 28% higher

In the study of 113,994 patients, the researchers found that the risk of breakthrough SARS-CoV-2 infection was low overall (3.8%) but was 28% higher in people living with the virus. HIV compared with people not infected with HIV (adjusted hazard ratio, 1.28; 95% CI, 1.19 – 1.37).

The breakthrough rate was also higher in the HIV group (55 cases per 1,000 person-years, compared to 43 cases per 1,000 person-years in people not infected with HIV).

The patients were from the Corona Infectious Virus Epidemiology Team (CIVET)-II of the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD), which is part of the International Epidemiology Databases to Evaluate (IeDEA) collaboration. AIDS), which includes four cohorts.

Among people living with HIV, those younger than 45 (vs those aged 45-54) and those with a history of COVID were more likely to experience breakthrough infections. Additionally, those who did not receive additional vaccines after the primary vaccination were more likely to have breakthrough infections, which amplifies the need for booster shots, the authors write.

The authors note that there was no association between breakthrough infections and suppression of HIV viral load, but high CD4 counts (>500 cells/mm3) were associated with fewer breakthroughs among people living with HIV.

Dr Monica Gandh

Monica Gandhi, MD, professor of medicine and associate division chief of HIV, infectious diseases and global medicine at the University of California, San Francisco, praised the study, noting that so far , large studies have not examined the rate of breakthrough infections among HIV-vaccinated and HIV-free people in the United States.

She said Medscape Medical News she agrees with the authors that a third dose for everyone living with HIV is needed because breakthrough rates of infections were high in all populations during the Omicron surge (which occurred largely after the period of this study).

She said she wasn’t convinced the third vaccine was needed before Omicron, because breakthrough rates in the HIV-positive and non-HIV-positive groups were low.

“However, the most interesting part of this study for me was how well the vaccines worked in people living with HIV with generally higher CD4 counts and virologic suppression, again telling us as HIV providers how well anti-HIV drugs work and how our HIV patients have relatively normal immune systems if treated,” she said.

One limitation of the study was that the study population was 92% male. Additionally, those who did not have regular access to health care (who may be at higher risk of contracting COVID) were less likely to be included in the study. Those engaged in care may seek more frequent COVID-19 testing, which could lead to higher detection of breakthrough infections than in the general population

“Future analyzes should consider testing practices and include a greater proportion of HIV-positive women,” the authors write. “Ultimately, policymakers must determine the appropriate balance between preventing new COVID-19 infections and possibly unnecessary additional vaccinations.”

Dr Keri Althoff

Co-author Keri Althoff, PhD, MPH, told Medscape that there is an unanswered question that would reinforce the CDC’s call to action: do people living with HIV have post-vaccination disease? More serious COVID-19?

“We have a second paper it is a preprint and currently undergoing peer review,” she said. “In this article, we found that people living with HIV with a CD4 count <350 cells/mm3 were more likely to be hospitalized due to post-vaccination breakthrough related to COVID-19 compared to similar people without HIV. “

At a minimum, Althoff said, policymakers should consider including people living with HIV with a CD4 <350 cells/mm3 (relaxing the restriction to <200 cells/mm3) in their recommendations for people with moderate or severe immunocompromised.

The research was supported by additional funds from the North American AIDS Cohort Collaboration on Research and Design. Coburn reports no relevant financial relationships. A co-author received grants from the Canadian Institutes of Health Research, Alberta Innovates, and the Cumming School of Medicine at the University of Calgary/Alberta Health Services outside of the submitted work. A co-author reports serving as a consultant to TrioHealth, Kennedy Dundas, and MedIQ outside of the submitted work.

JAMA Netw Open. Published online June 7, 2022.

Marcia Frellick is a Chicago-based freelance journalist. She has previously written for the Chicago Tribune, Science News and, and served as an editor for the Chicago Sun-Times, the Cincinnati Enquirer and the St. Cloud (Minnesota) Times. Follow her on Twitter at @mfrellick.

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