Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Pneumococcal immunization in HIV-infected adults

Patricia L Hibberd, MD, PhD
Section Editor
John G Bartlett, MD
Deputy Editor
Allyson Bloom, MD


Pneumococcal infections, including pneumonia and invasive disease such as bacteremia and meningitis, have been a major source of morbidity and mortality since the beginning of the HIV epidemic, leading many experts to endorse use of pneumococcal vaccine for primary prevention in HIV-infected patients [1]. However, the efficacy of pneumococcal vaccine in this patient population has been debated for many years [2]. In addition, pneumococcal vaccines are serotype-specific, so efficacy will also vary depending on the prevalent serotypes within the community.

This topic addresses data on the use of polysaccharide and conjugate pneumococcal vaccines in HIV-infected patients and suggestions for primary prevention. Data on the use of pneumococcal vaccines in the immunocompetent host are found elsewhere. Advice on the use of other vaccines in HIV-infected patients is discussed in detail elsewhere. (See "Immunizations in HIV-infected patients" and "Prevention of hepatitis B virus infection in the HIV-infected adult".)


Pneumococcal pneumonia and meningitis are leading causes of morbidity and mortality among HIV-infected patients worldwide and treatment is complicated by the increasing incidence of drug-resistant pneumococcal strains [3,4]. The overall incidence of invasive pneumococcal disease was 677 cases per 100,000 person-years in HIV-infected patients [3]. The case fatality rate of invasive disease ranges from 8 percent with pneumococcal bacteremia to 50 percent with meningitis [5,6].

A retrospective study performed in San Francisco, prior to the era of potent antiretroviral therapy (ART), found that the rates of pneumococcal bacteremia were approximately 100-fold greater in HIV-infected patients compared with those who were not infected with HIV [1]. In addition, recurrent invasive pneumococcal disease is common, occurring in up to 25 percent of patients within a year after the initial episode [7].

Risk factors — The most important risk factor for developing pneumococcal infections is the level of immunosuppression [7-10]. In one trial of pneumococcal vaccine efficacy, the vast majority of HIV-infected patients who developed invasive pneumococcal disease had a CD4 count <200 cells/mm3 [11].


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: Jul 4, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Redd SC, Rutherford GW 3rd, Sande MA, et al. The role of human immunodeficiency virus infection in pneumococcal bacteremia in San Francisco residents. J Infect Dis 1990; 162:1012.
  2. Pedersen RH, Lohse N, Østergaard L, Søgaard OS. The effectiveness of pneumococcal polysaccharide vaccination in HIV-infected adults: a systematic review. HIV Med 2011; 12:323.
  3. Jordano Q, Falcó V, Almirante B, et al. Invasive pneumococcal disease in patients infected with HIV: still a threat in the era of highly active antiretroviral therapy. Clin Infect Dis 2004; 38:1623.
  4. Iwajomo OH, Finn A, Moons P, et al. Deteriorating pneumococcal-specific B-cell memory in minimally symptomatic African children with HIV infection. J Infect Dis 2011; 204:534.
  5. Grau I, Pallares R, Tubau F, et al. Epidemiologic changes in bacteremic pneumococcal disease in patients with human immunodeficiency virus in the era of highly active antiretroviral therapy. Arch Intern Med 2005; 165:1533.
  6. Scarborough M, Gordon SB, Whitty CJ, et al. Corticosteroids for bacterial meningitis in adults in sub-Saharan Africa. N Engl J Med 2007; 357:2441.
  7. Gilks CF, Ojoo SA, Ojoo JC, et al. Invasive pneumococcal disease in a cohort of predominantly HIV-1 infected female sex-workers in Nairobi, Kenya. Lancet 1996; 347:718.
  8. Barry PM, Zetola N, Keruly JC, et al. Invasive pneumococcal disease in a cohort of HIV-infected adults: incidence and risk factors, 1990-2003. AIDS 2006; 20:437.
  9. Dworkin MS, Ward JW, Hanson DL, et al. Pneumococcal disease among human immunodeficiency virus-infected persons: incidence, risk factors, and impact of vaccination. Clin Infect Dis 2001; 32:794.
  10. Gebo KA, Moore RD, Keruly JC, Chaisson RE. Risk factors for pneumococcal disease in human immunodeficiency virus-infected patients. J Infect Dis 1996; 173:857.
  11. French N, Gordon SB, Mwalukomo T, et al. A trial of a 7-valent pneumococcal conjugate vaccine in HIV-infected adults. N Engl J Med 2010; 362:812.
  12. Ho J, Moir S, Malaspina A, et al. Two overrepresented B cell populations in HIV-infected individuals undergo apoptosis by different mechanisms. Proc Natl Acad Sci U S A 2006; 103:19436.
  13. Teshale EH, Hanson D, Flannery B, et al. Effectiveness of 23-valent polysaccharide pneumococcal vaccine on pneumonia in HIV-infected adults in the United States, 1998--2003. Vaccine 2008; 26:5830.
  14. Payeras A, Martinez P, Milà J, et al. Risk factors in HIV-1-infected patients developing repetitive bacterial infections: toxicological, clinical, specific antibody class responses, opsonophagocytosis and Fc(gamma) RIIa polymorphism characteristics. Clin Exp Immunol 2002; 130:271.
  15. Peñaranda M, Falco V, Payeras A, et al. Effectiveness of polysaccharide pneumococcal vaccine in HIV-infected patients: a case-control study. Clin Infect Dis 2007; 45:e82.
  16. Sogaard OS, Lohse N, Gerstoft J, et al. Hospitalization for pneumonia among individuals with and without HIV infection, 1995-2007: a Danish population-based, nationwide cohort study. Clin Infect Dis 2008; 47:1345.
  17. Guerrero M, Kruger S, Saitoh A, et al. Pneumonia in HIV-infected patients: a case-control survey of factors involved in risk and prevention. AIDS 1999; 13:1971.
  18. Rosen JB, Thomas AR, Lexau CA, et al. Geographic variation in invasive pneumococcal disease following pneumococcal conjugate vaccine introduction in the United States. Clin Infect Dis 2011; 53:137.
  19. Hampton LM, Farley MM, Schaffner W, et al. Prevention of antibiotic-nonsusceptible Streptococcus pneumoniae with conjugate vaccines. J Infect Dis 2012; 205:401.
  20. Jain A, Jain S, Gant V. Should patients positive for HIV infection receive pneumococcal vaccine? BMJ 1995; 310:1060.
  21. French N, Nakiyingi J, Carpenter LM, et al. 23-valent pneumococcal polysaccharide vaccine in HIV-1-infected Ugandan adults: double-blind, randomised and placebo controlled trial. Lancet 2000; 355:2106.
  22. Watera C, Nakiyingi J, Miiro G, et al. 23-Valent pneumococcal polysaccharide vaccine in HIV-infected Ugandan adults: 6-year follow-up of a clinical trial cohort. AIDS 2004; 18:1210.
  23. Carson PJ, Schut RL, Simpson ML, et al. Antibody class and subclass responses to pneumococcal polysaccharides following immunization of human immunodeficiency virus-infected patients. J Infect Dis 1995; 172:340.
  24. Janoff EN, Fasching C, Ojoo JC, et al. Responsiveness of human immunodeficiency virus type 1-infected Kenyan women with or without prior pneumococcal disease to pneumococcal vaccine. J Infect Dis 1997; 175:975.
  25. Rodriguez-Barradas MC, Musher DM, Lahart C, et al. Antibody to capsular polysaccharides of Streptococcus pneumoniae after vaccination of human immunodeficiency virus-infected subjects with 23-valent pneumococcal vaccine. J Infect Dis 1992; 165:553.
  26. Loeliger AE, Rijkers GT, Aerts P, et al. Deficient antipneumococcal polysaccharide responses in HIV-seropositive patients. FEMS Immunol Med Microbiol 1995; 12:33.
  27. Weiss PJ, Wallace MR, Oldfield EC 3rd, et al. Response of recent human immunodeficiency virus seroconverters to the pneumococcal polysaccharide vaccine and Haemophilus influenzae type b conjugate vaccine. J Infect Dis 1995; 171:1217.
  28. Søgaard OS, Schønheyder HC, Bukh AR, et al. Pneumococcal conjugate vaccination in persons with HIV: the effect of highly active antiretroviral therapy. AIDS 2010; 24:1315.
  29. Lesprit P, Pédrono G, Molina JM, et al. Immunological efficacy of a prime-boost pneumococcal vaccination in HIV-infected adults. AIDS 2007; 21:2425.
  30. Glesby MJ, Watson W, Brinson C, et al. Immunogenicity and Safety of 13-Valent Pneumococcal Conjugate Vaccine in HIV-Infected Adults Previously Vaccinated With Pneumococcal Polysaccharide Vaccine. J Infect Dis 2015; 212:18.
  31. Bhorat AE, Madhi SA, Laudat F, et al. Immunogenicity and safety of the 13-valent pneumococcal conjugate vaccine in HIV-infected individuals naive to pneumococcal vaccination. AIDS 2015; 29:1345.
  32. Moore CE, Paul J, Foster D, et al. Reduction of invasive pneumococcal disease 3 years after the introduction of the 13-valent conjugate vaccine in the Oxfordshire region of England. J Infect Dis 2014; 210:1001.
  33. Søgaard OS, Lohse N, Harboe ZB, et al. Improving the immunogenicity of pneumococcal conjugate vaccine in HIV-infected adults with a toll-like receptor 9 agonist adjuvant: a randomized, controlled trial. Clin Infect Dis 2010; 51:42.
  34. FDA expands use of Prevnar 13 vaccine for people ages 50 and older. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm285431.htm (Accessed on January 03, 2012).
  35. Prevnar 13 - Highlights of prescribing information. http://www.fda.gov/downloads/BiologicsBloodVaccines/Vaccines/ApprovedProducts/UCM201669.pdf (Accessed on January 03, 2012).
  36. Centers for Disease Control and Prevention (CDC). Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine for adults with immunocompromising conditions: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep 2012; 61:816.
  37. Kim DK, Bridges CB, Harriman KH, Advisory Committee on Immunization Practices. Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older: United States, 2016. Ann Intern Med 2016; 164:184.
  38. Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: Recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America http://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf (Accessed on July 22, 2013).
  39. Department of Health and Human Services. Panel on Opportunistic Infections in HIV-Exposed and HIV-Infected Children. Guidelines for the prevention and treatment of opportunistic infections in HIV-exposed and HIV-infected children. Available at: aidsinfo.nih.gov/contentfiles/lvguidelines/oi_guidelines_pediatrics.pdf (Accessed on November 20, 2013).
  40. Rubin LG, Levin MJ, Ljungman P, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis 2014; 58:e44.
  41. Rodriguez-Barradas MC, Serpa JA, Munjal I, et al. Quantitative and Qualitative Antibody Responses to Immunization With the Pneumococcal Polysaccharide Vaccine in HIV-Infected Patients After Initiation of Antiretroviral Treatment: Results From a Randomized Clinical Trial. J Infect Dis 2015; 211:1703.