BHIVA update guidance on shingles vaccine

9 January 2024. Related: Guidelines, Coinfections and complications, Basic science and immunology, Vaccines and microbicides, BHIVA news.

Simon Collins, HIV i-Base

On 9 January 2024, BHIVA publicised recent guidance on use of shingles vaccines by people living with HIV in the UK. [1]

This information was produced because BHIVA recommend a different vaccine strategy compared to the advice for the general population. Current guidance in the Green Book might inadvertently lead to inappropriate care for people living with HIV. [2]

This update to the BHIVA vaccination guidelines includes the following recommendations.

People living with HIV with a CD4 count <200 cells/mm³ should be offered Shingrix rather than Zostavax.*

This is due to better efficacy. It also has fewer cautions (such as uncertain VZV immune status related to chickenpox).

People living with HIV and an additional medical concern that affects the immune system (for example using chemotherapy), should be offered Shingrix irrespective of their CD4 count.
People living with HIV aged over 50 who are virally suppressed with a CD4 count >200 cells/mm³ do not need vaccination (even though recommended in the Green Book). Especially as there are currently shingles vaccine shortages.
All people aged 70-80 should be offered the vaccine and anyone older than 65, if this birthday was after September 2023.
HIV clinics should provide clear information to GP-based services, detailed in the full BHIVA position statement. [1]
BHIVA also helpfully include a non-technical information sheet on shingles and vaccination for people living with HIV. [3]

Please see the BHIVA document for full details and the community leaflet included below.

*Shingrix is a recombinant shingles vaccine. Zostavax is a live attenuated vaccine that should now be replaced by Shingrix but is still sometimes being used.

References

BHIVA position statement on shingles vaccine for people living with HIV. (23 December 2023).
https://www.bhiva.org/file/65856b2759326/BHIVA-position-statement-on-shingles-vaccine-for-people-living-with-HIV.pdf
Gov.uk. Green Book. Immunisation against infectious disease. (Updated November 2020).
https://www.gov.uk/government/collections/immunisation-against-infectious-disease-the-green-book
BHIVA. Appendix 1. (23 December 2023).
https://www.bhiva.org/file/65856b2759326/BHIVA-position-statement-on-shingles-vaccine-for-people-living-with-HIV.pdf

Appendix 1. Example patient information leaflet What is shingles?

Shingles (herpes zoster) is caused by the chickenpox virus (also called varicella zoster virus or VZV).

VZV stays sleeping in the body of anyone who has had chickenpox in the past. In some people, it can reactivate, or reawaken, causing shingles. Typically, this causes a rash, with redness, blisters and pain/tingling on a patch of skin. It usually gets better, but some people are left with long-term pain which is called post-herpetic neuralgia or PHN.

Shingles is more common in people whose immune systems are weakened by other conditions or treatments, such a chemotherapy. Everyone experiences a decline in their immune system with older age. This is one of the main risk factors for shingles. PHN is more common at older ages. This is why the national vaccine programme focuses on people aged 65 and older.

Can shingles be passed on to other people?

People who are already VZV-immune, because they have been vaccinated or because they have had chickenpox in the past, cannot get the virus from someone with shingles. People who are not VZV-immune could acquire the virus from someone with shingles; this would result in them getting chickenpox.

If you have shingles, you should avoid contact with anyone not VZV-immune and ensure any affected areas are covered; try to avoid people with severely damaged immune systems (for example some people on chemotherapy for cancer), pregnant women who have not had chickenpox and very young babies (less than 1 month old).

Do I need a shingles vaccine?

Most people living with HIV require a shingles vaccine only when they meet the relevant age cut-off:

All people aged 70–79 years of age; once you are 80 or older you are no longer eligible as there is not enough evidence of benefit.
Anyone turning 65 years of age on or after 1 September 2023; if you turned 65 before this date you need to wait until you are 70 years old. This may seem complicated but is designed to gradually extend the age group of people who are eligible for vaccines to avoid overwhelming the system. Some people living with HIV require a shingles vaccine from the age of 50. This includes:
People with a CD4 count less than 200 cells/mm³.
People with another condition or receiving treatment that affects their immune system (e.g. some cancer treatments), regardless of their CD4 count.

Is the shingles vaccine safe?

There are two types of shingles vaccine:

Shingrix: a non-live vaccine.
Zostavax: a live vaccine.

Both are safe when used correctly. Live vaccines should usually not be used in people living with HIV if their CD4 count is less than 200 cells/mm³. Some live vaccines, such as BCG (a tuberculosis vaccine), should not be used in anyone with HIV regardless of their CD4 count.

If your CD4 count is less than 200 cells/mm³ you should only receive Shingrix.

If your CD4 count is more than 200 cells/mm³ you can receive either type of shingles vaccine. We recommend Shingrix as it is more effective. It can be given whether or not you are VZV-immune.

Zostavax should only be given if you know you are VZV-immune, either because you have already had chickenpox or because you have had a chickenpox vaccine in the past. Your HIV clinic or GP can check if you are not sure.

If you know you are VZV-immune: Zostavax is safe.
If you are not sure: your VZV immunity can be checked.
If you are not VZV-immune: you should receive Shingrix, not Zostavax. If Shingrix is not available, you will need to have two doses of the chickenpox vaccine (Varivax). This will make you VZV-immune, so that you can then receive Zostavax. The chickenpox vaccine is similar to Zostavax but with much lower levels of live virus, and is safe to use as long as your CD4 count is greater than 200 cells/mm³.