Wednesday 12 May 2021
Most COVID vaccines will be arranged via primary care. For people not registered with a GP, or those who have not disclosed their HIV status, HIV clinics in Wales, Scotland, Northern Ireland and England can refer directly to vaccine hubs. It may take a while for individual clinics to get the necessary pathways arranged, and numbers may be limited, but patients should contact their clinic for more information if they are unable to access the vaccine through their GP. Some HIV services are offering vaccines within the HIV clinic so people should be advised to check with their local service.
Currently in the Republic of Ireland vaccines can only be accessed via GPs. We will update this information as required and a summary of current practice in each country is in the table below (Appendix 1.)
Central vaccine databases will not include medical information, just basic details and the date a vaccine is given.
People without an NHS number should be able to access vaccines.
DHSC recommend vaccinating the household members of anyone who has a suppressed immune system, including all people living with HIV. This advice is based on the possibility that the COVID vaccine will be less protective for people with a suppressed immune system so vaccinating their close contacts will reduce the risk of getting COVID at home.
People who are immunosuppressed will be able to invite their household contacts for earlier vaccination. If someone is not comfortable to do this, and their HIV is well-controlled on treatment (undetectable viral load and CD4 more than 350) then we do not think it is urgent to do so. However, anyone who has had a recent HIV-related illness, or who currently has a CD4 count less than 350 or a detectable viral load is strongly encouraged to invite their household contacts to have a vaccine – they do not need to tell them why, just that they are at higher risk (e.g. based on QCovid assessment, see below).
Data on how protective the COVID vaccines are in people with HIV remains limited but there is some data from a pre-print of a study of the Astra Zeneca vaccine in 54 men living with well-controlled HIV (all were undetectable on antiretrovirals with an average CD4 just under 700). The side effect profile and the measured immune response (both B and T cell responses) were similar to those seen in HIV-negative people. Likewise, a pre-print study of the same vaccine in South Africa showed similar safety and measured immune responses in 52 people with HIV (again stable on treatment with an average CD4 just below 700) compared to 28 HIV-negative people.
These data are reassuring but we need more information about how long protection lasts (and whether this differs for people with HIV) and vaccine responses in people who are not undetectable or have lower CD4 counts.
France has recommended that people with immunosuppression have a 3rd vaccine dose, but there is no evidence yet to support an extra dose, and they do not include HIV on the list of conditions where a 3rd dose is advised. Currently in the UK 3rd doses are not recommended, and testing immune response to vaccine is not performed routinely, only in research studies.
At the time of writing the advice to shield has ended but people on the ‘clinically extremely vulnerable’ list are still advised to follow guidance strictly and to take extra precautions where they can, including working from home where possible. Everyone in this group should have been vaccinated by now.
The QCovid calculation is available online but not recommended for informing clinical decision-making. The application of the QCovid risk calculator in England is summarised here: https://digital.nhs.uk/coronavirus/risk-assessment/population. QCovid is based on a combination of factors which include ethnicity, housing, obesity and specific health conditions. This affects many people, both with and without HIV. If someone with HIV has been added to the Shielded Patient list it may be for non-HIV reasons or it may be wrong. Anyone can be removed from the clinically extremely vulnerable list by their GP; people can also be added to the list by their GP or HIV clinic.
There may still be specific support available to people considered clinically extremely vulnerable which will vary by council and can be checked here: https://www.gov.uk/coronavirus-local-help
Last year there were cases where people who were NOT at high risk were advised to shield because the guidance had been issued based on inaccurate information. NHS Digital and DHSC are aware of some of the reasons for this and are continually updating the ways they assess risk. Anyone who was removed from the ‘extremely clinically vulnerable’ list last year (also called ‘the shielding list’) will not have been included in the QCovid risk assessments – here the advice is for a GP or secondary care service to recalculate someone’s risk and information about how to access, and register to use, the tool is here: https://digital.nhs.uk/coronavirus/risk-assessment/clinical-tool
QCovid flags someone as ‘clinically extremely vulnerable’ if their risk of dying from COVID is at least 10 times higher than it would be for someone of the same age without additional risk factors. HIV is considered in the calculation but HIV alone would not be enough to put someone in the higher risk group. An important issue to consider is relative versus absolute risk: a 10 x higher risk of severe COVID in those with HIV (relative risk) sounds very alarming BUT if the actual risk of getting severe COVID in those without HIV is only 1 in 20,000 (absolute risk in those without HIV), then this would mean that the absolute risk in those with HIV would be 1 in 2,000 which is still a LOW RISK. The risk of getting COVID will also depend on how common COVID is in the population, whether you follow social distancing guidance and hygiene recommendations like washing your hands, and vaccination. Current risk calculations will evolve over time to reflect this.