This guidance was updated on 16 September 2021; click here to see that update
Friday 3 September 2021
On 1 September 2021 the Joint Committee on Vaccination and Immunisation (JCVI) produced advice on a third primary COVID-19 vaccine dose for people with immunosuppression at the time of their first two vaccine doses . The guidance applies to all people aged 12 or older.
A third primary dose is conceptually different to a booster because it is intended to improve response to the initial vaccine course in people less likely to respond, whereas a booster enhances immunity in those who have already had their initial vaccine course and will most likely have experienced an optimal response to this. People who receive a third dose will still be eligible for booster doses (probably 6 months after their most recent primary dose) in line with yet undetermined national guidance on routine boosters for the general population.
There are several indications for a third COVID-19 vaccine dose including leukaemia, aggressive lymphomas, other lymphoproliferative conditions and receiving a stem cell transplant. People with HIV are recommended to have a third vaccine dose if their CD4 count was less than 200 cells/mm3 at the time of initial vaccination. However, the advice is that there is room for clinical judgement in deciding who should have a third dose, and the JCVI supports individualised decision making.
Evidence to guide specific advice for people with HIV is scant, and there are limited data on the relative impacts on natural and vaccine-induced immunity of current CD4 count, CD4:CD8 ratio and detectable viral load. Some inferences can be made from studies of other vaccines in people living with HIV.
We recommend a third COVID-19 vaccine dose for all people with a CD4 count less than 200 cells/mm3 at the time of initial vaccination.
We suggest that the following groups are also offered a third vaccine dose:
1) People with clinical manifestations of HIV-related immune suppression (e.g. recent AIDS-defining conditions, tuberculosis), regardless of CD4 count, within a year prior to receiving the first COVID-19 vaccine;
2) People not on recommended antiretroviral therapy (elite controllers with consistently high CD4 counts are NOT thought to need a third dose);
3) People with persistent or intermittent viraemia where their clinician has assessed that a third dose is recommended.*
*Most data on the immunological responses to COVID-19 vaccination in people with HIV come from people virally suppressed on antiretroviral therapy; the impact of viraemia is therefore difficult to predict. We suggest that, while viraemia per se is not an indication for a third dose, an individualised decision to offer a third vaccine dose can be made in the presence of viraemia in the context of other possible risk factors for suboptimal vaccine response (e.g. CD4 count <350 cells/mm3, CD4:CD8 ratio <0.5, CD4 nadir <200 cells/mm3).
Clarity regarding central mechanisms to inform those who are eligible for a third vaccine is awaited; it is not known whether the same coding used to generate the ‘shielding list’ will also be used to identify those in need of an additional vaccine.
In the interim, HIV services should proactively identify and contact people with HIV who need a third dose. HIV clinics are advised to inform GPs where someone should have a third dose, and any specific details regarding timings. Arrangements for people not registered with a GP are unknown at present. The intention is that some form of declaration letter will permit eligible people to attend vaccine services; further detail is pending.
Based on JCVI advice in general, and for other immunosuppressive conditions:
The third dose should be given at least 8 weeks after the second dose;
Timing of a third dose relative to starting/restarting antiretroviral therapy should be considered (e.g. for someone who has recently started antiretroviral therapy, deferring a third dose until they have achieved viral suppression may be sensible).
The JCVI recommends that the third dose should be an mRNA vaccine. People whose initial course was with the AstraZeneca vaccine can have a third AstraZeneca dose where this would facilitate delivery. Only exceptionally should someone whose initial course was with an mRNA vaccine be given a third dose with the AstraZeneca vaccine; there are no specific circumstances in which this would be recommended for someone with HIV unless they are at high risk of infection or reinfection and unable to access an mRNA vaccine.
Immunity testing is not recommended routinely and where people may have had testing it is not recommended that the results should influence the decision to offer a third dose at present. Data are awaited to determine the value of serological antibody testing in guiding vaccination against SARS-CoV-2 in people living with HIV.
1. Department of Health and Social Care. Independent report. Joint Committee on Vaccination and Immunisation (JCVI) advice on third primary dose vaccination. 1 September 2021. Available at: https://www.gov.uk/government/publications/third-primary-covid-19-vaccine-dose-for-people-who-are-immunosuppressed-jcvi-advice/joint-committee-on-vaccination-and-immunisation-jcvi-advice-on-third-primary-dose-vaccination (accessed September 2021).