This guidance was updated on 24 September 2021; click here to see that update

Thursday 16 September 2021

On the 1st September 2021 the Joint Committee on Vaccination and Immunisation (JCVI) produced advice on third primary dose COVID vaccination for people with immunosuppression at the time of their first two vaccine doses [1]. The guidance applies to all people aged 12 or older.

A third primary dose is conceptually different to a booster since it is intended to improve response to the initial vaccine course in people less likely to respond whereas as booster enhances immunity in those likely to have experienced an optimal response to initial vaccine. People who receive a third dose will still be eligible for booster doses (likely 6 months after their most recent primary dose) in line with, yet undetermined, national guidance on routine boosters. It is not recommended to routinely measure immune responses after vaccination to determine the need for a third dose.

There are several indications for a third COVID vaccine dose including leukaemia, aggressive lymphomas, other lymphoproliferative conditions, and people who have received a stem cell transplant. People with HIV are recommended to have a third vaccine dose if their CD4 was less than 200 cells/mm³ at the time of initial vaccination. There is room for clinical judgement in deciding who should have a 3rd dose and the JCVI support individualised decision making.

Evidence to guide specific advice for people with HIV is scant, and the relative impact on natural and vaccine-induced immunity of current CD4, CD4:8 ratio and detectable viral load is unknown.

We recommend a third COVID vaccine dose for all people with a CD4 less than 200 cells/mm³ at the time if 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, regardless of CD4 (e.g. 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 antiretroviral therapy.

Logistics

Instructions for services are summarised here: https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2021/09/C1399-Updated-JCVI-guidance-for-vaccinating-immunosuppressed-individuals-with-third-primary-dose.pdf

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 regarding timings. Annex B of the logistics document includes a template letter. GPs have been informed of the need to offer third doses but, depending on your local pathways, we suggest contacting local GPs to check they are prepared. There is no central booking mechanism – for people not registered with a GP, or who have not shared their HIV status with their GP, you are advised to explore local options for referring directly to a vaccine hub. If you work within a Trust that does run 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.

Timings

Based on JCVI advice in general, and for other immunosuppressive conditions:

• The 3rd dose should be given at least 8 weeks after the 2nd

• The 3rd dose should be deferred until someone who has initiated or reinitiated antiretroviral therapy has been virally suppressed for 6 months.

Vaccine type

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 an AstraZeneca third dose; there are no specific circumstances where this would be recommended for someone with HIV unless they are at high risk of reinfection and unable to access an mRNA third dose.

Reference

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

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