Is the recommendation for pneumococcal vaccination of HIV patients evidence based?

Background: both the current NHMRC guidelines of Australia and the USPHS/IDSA guidelines recommend pneumococcal vaccine be given to all patients with HIV infection despite a paucity of data to support these recommendations. Objectives: the aim of this study was to assess the incidence of invasive pneumococcal disease and use of pneumococcal vaccine in HIV-infected patients at The Alfred Hospital, Melbourne, Australia, and to review the evidence for the current recommendations. Study design: a case record review of all HIV-infected patients followed at The Alfred Hospital diagnosed with pneumonia between 1 June 1996 and 1 June 2000 was performed. Main outcome measures were the incidence of invasive pneumococcal disease and the proportion of these individuals who received pneumococcal vaccination. Results: invasive pneumococcal disease was a relatively infrequent event with an incidence of 1.9 per 1000 person years. This rate is lower than the 8.2 per 1000 person years reported for confirmed disease by CDC. Of the 34 patients with either definite invasive, presumptive or possible pneumococcal disease, 16 (47%) had received pneumococcal vaccine, seven of these within 5 years prior to the episode of pneumonia. In 15 cases, the vaccine was administered when the CD4 cell count was < 500 per μl. Conclusion: lack of efficacy data, rarity of invasive disease plus evidence of infrequent administration delivered predominantly to those who are least likely to benefit, has prompted us to question the value of routinely vaccinating all our HIV-infected patients with pneumococcal vaccine. Review of the published literature provides conflicting data in support of the current recommendations for administration of pneumococcal vaccine in HIV patients. It may be more cost-effective to concentrate efforts on strategies to improve adherence to ARV therapy, as this has unequivocally been shown to be associated with a reduction in the incidence of pneumococcal disease.