Vaccinations

  • Some ‘live’ vaccines are not safe for people with HIV, especially those with low CD4 counts.

  • Travellers to some countries may be legally obliged to be vaccinated against yellow fever, which is a live vaccine.

Travel vaccines can help protect people from illnesses that are common in foreign countries. Not only is it important to find out which vaccinations are recommended for travel to a particular country, it is also necessary to check if they are safe for people with HIV. Some vaccines should not be administered if an individual’s immune system has been compromised or weakened severely by HIV, as he or she could become ill.

Travel vaccines are provided by a number of different healthcare organisations in the UK. Some general practitioners (GPs) or practice nurses have taken an interest in the area and provide advice and some specialised travel clinics are allied to hospitals. There are also lots of private providers. Most specialists in travel medicine will have knowledge of vaccines which are safe for people with HIV, but this would involve discussing HIV status. Since not everyone is comfortable with disclosing their HIV status, it can be helpful for HIV-positive travellers to talk to their HIV doctor about vaccines in the first instance. This is a good way to make sure someone is safe and protected from illnesses while travelling. Wherever someone goes for their travel vaccinations, it is vital that they have discussed their HIV status to ensure that they get the appropriate vaccinations and do not risk their health.

Vaccines can either be ‘live’ or ‘inactive’. Live vaccines are usually created from a weakened version of the virus or bacteria that is being vaccinated against. Inactive vaccines contain killed versions of the pathogen, or a fragment of it. It is the live vaccines that can cause problems for some people with HIV.

Traditionally, live vaccines have been contraindicated in HIV infection, which meant that they should not be used. In the past, most people with HIV had severely damaged immune systems and so risked becoming ill if given a live vaccine. Even in a weakened form, the pathogen in the vaccine could have made people with HIV very ill.

However, due to the impact of current HIV treatments there has been a shift in the risk–benefit ratio in favour of vaccination. Current HIV treatments have led to many HIV-positive people having immune systems that are able to cope with live vaccines. There are exceptions, which is why vaccines should be discussed with a healthcare professional. Those with a low CD4 count may still be unable to take some vaccines.

Important examples of live vaccines that should be used cautiously alongside HIV infection include those for measles, mumps and rubella (MMR) and yellow fever. Other live vaccines remain contraindicated, either because safer inactivated alternatives are available (e.g. typhoid) or because of a lack of safety data.

Recommendations do change from time to time which is why it is important that requirements should be discussed with a doctor.

The following gives an overview of common travel-related vaccines and their use in those with HIV.1 Full guidance can be found in the British HIV Association guidelines on immunisation at www.bhiva.org/documents/Guidelines/Immunisation/Immunization2008.pdf

Meningococcus (ACWY)

This vaccine is recommended for travel to endemic or epidemic areas and is mandatory for travel to some countries. It can be used safely for most people with HIV.

 

Yellow fever

This vaccine should be considered only if there is a true risk of infection. It should not be given to those with symptomatic HIV infection or with severely weakened immune systems (CD4 counts less than 200 cells/mm3).

Hepatitis B

This is recommended for prolonged travel. Hepatitis B vaccination is recommended for all people with HIV, whether they travel or not.

Measles, mumps, rubella (MMR)

This vaccine should only be used if necessary and should not be given to those with symptomatic HIV infection or with severely weakened immune systems (CD4 counts less than 200 cells/mm3).

Tetanus-diphtheria /parenteral poliomyelitis(Td /IPV)

This vaccine should be topped up every 10 years and requirements should be checked before travel.

The following vaccines are for selective use for travellers to areas with a risk of transmission:

  • cholera (WC /rBS)  

  • hepatitis A                    

  • Japanese encephalitis          

  • tick-borne encephalitis  

  • typhoid (ViCPS)           

  • rabies.   

Recommendations for these vaccines depend on the countries of destination, the epidemic situation at the time of travel, the purpose of travel, the intended length of stay and the health status of the traveller. Because recommendations will change from time to time, it is important for doctors to access up-to-date health information for specific destinations. This is available from the Centers for Disease Control and Prevention at www.cdc.gov/travel/default.aspx and the World Health Organization at www.who.int/ith/en/

Vaccinations and routine blood tests

As vaccines can stimulate the immune system, they can affect routine blood-test results at an HIV clinic. It is important for someone with HIV to tell their HIV doctor if they are having, or have had, travel vaccinations to make sure this is considered when interpreting blood-test results.

Mandatory vaccinations

Some vaccines are mandatory for travel to selected countries. These vaccines are legal requirements for travel. Failure to obtain the vaccine could result in non-entry or quarantine at the destination. This is particularly important for people with HIV who have very weak immune systems (CD4 counts less than 200 cells/mm3) and so cannot have the vaccine for yellow fever.

If someone with HIV has a CD4 count which is too low for the yellow fever vaccination, their HIV doctor can issue a certificate of exemption. However, this waiver may not be accepted by all countries and may carry information about HIV status. For a full list of restrictions based on yellow fever vaccine certification, see Countries and their restrictions.

Countries requiring a certificate of yellow fever vaccination can be found in all parts of the world. However, in many cases, they will only require this if there has been recent travel to areas at risk of yellow fever transmission. Those areas considered to be at risk can vary, but are generally in Africa, Central and South America, for example:

Africa: Angola, Benin, Burkina Faso, Burundi, Cape Verde, Cameroon, Central African Republic, Chad, Congo, Democratic Republic of the Congo, Djibouti, Equatorial Guinea, Ethiopia, Gabon,  Gambia, Ghana, Guinea, Guinea-Bissau, Ivory Coast, Kenya, Liberia, Madagascar, Mali, Mauritania, Mozambique, Niger, Nigeria, Rwanda, São Tomé and Príncipe, Senegal, Sierra Leone, Somalia, Sudan, Tanzania, Togo, Uganda, Zambia.

Central America: Belize, Costa Rica, Panama

South America:  Bolivia, Brazil, Colombia, Ecuador, French Guiana, Guyana, Peru, Suriname, Trinidad and Tobago, Venezuela.

Yellow fever and India

India provides a good example of why it is important for HIV-positive travellers to check regulations before travelling, particularly if they are unable to be vaccinated for yellow fever.

India has a long list of countries and areas regarded as at risk of yellow fever transmission and when a case of yellow fever is reported from any country, that country is added to the list. Anyone arriving within six days of departure from an area on this list, or who has been in such an area in transit (except infants ≤six-months’ old), must carry a vaccine certificate or they will be detained in isolation for up to six days. The same applies to anyone who has come on a ship that started from, or touched at, any port in a yellow fever area, with a risk of yellow fever transmission, up to 30 days before its arrival in India, unless such a ship has been through a disinfection procedure.  

This kind of regulation means that the list of countries considered at risk of yellow fever transmission can change quickly. It is beneficial to check vaccination requirements and entry restrictions for any country before booking a trip and again before departure.

References

  1. Geretti AM on behalf of the BHIVA Immunization Writing Committee British HIV Association Guidelines for Immunization of HIV-infected Adults 2008 HIV Medicine, 2008
This content was checked for accuracy at the time it was written. It may have been superseded by more recent developments. NAM recommends checking whether this is the most current information when making decisions that may affect your health.
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This content was checked for accuracy at the time it was written. It may have been superseded by more recent developments. NAM recommends checking whether this is the most current information when making decisions that may affect your health.

NAM’s information is intended to support, rather than replace, consultation with a healthcare professional. Talk to your doctor or another member of your healthcare team for advice tailored to your situation.