Friday 17 December 2021
BHIVA strongly encourages all people living with HIV to have the recommended COVID vaccines. Data in people with HIV show no differences in terms of safety – there is some evidence for lower response to the first vaccine dose, but not the second, and some evidence that people with immune suppression respond less well, hence recommendations for a third dose for some people with HIV.
We recommend all clinics have clear, accessible patient information on vaccines.
Boosters
At the time of writing all people aged 18 or over are eligible for a booster dose 3 months after their 2nd (or 3rd) primary dose. This includes all people living with HIV.
Third doses
A third primary dose is conceptually different to a booster:
A third dose is intended to improve response to the initial vaccine course in people who are less likely to have responded. It is therefore part of the “primary” vaccine course.
A booster enhances immunity in those likely to have experienced an optimal response to the initial vaccine but whose immunity has naturally waned over time.
The Joint Committee on Vaccination and Immunisation (JCVI) recommends third vaccine doses for people with immunosuppression at the time of their first two vaccine doses [1]. It is not recommended to routinely measure immune responses after vaccination to determine the need for a third dose. The guidance applies to all people aged 12 or older and eligible people who have not yet received a 3rd dose should be encouraged to do so as soon as possible.
The JCVI recommends a 3rd vaccine for anyone with a CD4 <200 cells/mm3. There is room for clinical judgement so BHIVA also suggests a 3rd vaccine is offered to the following groups:
1) People with clinical manifestations of HIV-related immune suppression, regardless of CD4 (eg AIDS-defining conditions, tuberculosis);
2) People with persistent or recurrently detectable plasma HIV-RNA after more than 12 months on antiretroviral therapy;
3) People not on recommended antiretroviral therapy (this does not apply to people who maintain good immune markers off ART eg elite controllers).
People with HIV who do not have an HIV-related need for a third vaccine but have another relevant immunosuppressive condition should be offered a third dose.
Please note:
People who receive a 3rd dose can have a booster dose from 3 months after this.
People who have had a 3rd dose who were not eligible should be advised that they do not need additional vaccination at present.
Logistics
Boosters
Online booking is available for all who are eligible for a booster.
Boosters and third doses will be coded differently. Ultimately, as long as people in need of a third dose get a third vaccine, it’s not overly important whether that is coded as a third dose, or a booster. We recommend services keep a record of patients eligible for a third dose so they can be advised that they should also have a booster (ie 4 doses in total).
Third doses
The logistics and a template invitation letter have been communicated by letter [3].
It is down to specialist services and/or GPs to identify and inform people who are eligible for a third vaccine dose - there is no planned central mechanism.
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 specifics related to timings (see below).
GPs have been informed of the need to offer third doses.
Like boosters, 3rd doses can be booked online. For people who do not want to share their HIV status, please explore local options for referring directly to a vaccine hub. If you work within a Trust that runs a vaccine hub this should be relatively straightforward, if not we suggest liaising with other centres in your network who may be able to assist. Otherwise contact your local ICS or CCG lead.
Timings
Based on JCVI advice:
Boosters should be given at least 3 months after the second or third vaccination in the primary course.
The third dose, if required, should be given at least 8 weeks after the second and as soon after that time point as possible;
This is where advice to patients and GPs must be particularly clear; there is a risk that people who need a third dose, but access it as a booster, will have their third dose delayed inappropriately.
Of note, some people with HIV are being offered a third dose when they do not meet the criteria – this vaccine will, in effect, be their booster. The only issue here is that they could receive their booster dose early (ie less than 3 months after their second vaccine); this should not cause any problems.
Vaccine type
JCVI recommends that the third dose should be an mRNA vaccine. People whose initial course included at least one dose of AstraZeneca can have an AstraZeneca booster where mRNA vaccines are contra-indicated. Only exceptionally should someone aged 40 years or over whose initial course was mRNA be given an AstraZeneca booster.
References
1) 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
2) Greenbook COVID-19 chapter 14a (publishing.service.gov.uk)
3) C1399-Updated-JCVI-guidance-for-vaccinating-immunosuppressed-individuals-with-third-primary-dose.pdf (england.nhs.uk)
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