by Jeffrey T. Kirchner, DO, AAHIVS, AAHIVM Chief Medical Officer

July 9, 2019

Featured Literature:

Gilbert L et al. Herpes Zoster rates continue to decline in people living with HIV but remain higher than rates reported in the general US Population.
Clinical Infectious Diseases® 2019; 69(1):155–158.

Data from several HIV cohorts have found a 40% decline in the incidence of Herpes Zoster (HZ) in the modern ART era. However, the rate of HZ is still 3 to 5 times higher in persons with HIV compared to the general population. This paper looked at data from the U.S. Military HIV Natural History Study (NHS) – a cohort of more than 6100 HIV-infected Department of Defense beneficiaries who are followed at six military facilities. At each office visit, clinical diagnoses (including HZ) are obtained by patient interviews and review of the medical record. From the time it began collecting data in 1986, the NHS recorded 858 cases of HZ. Not surprisingly, the highest rates of HZ were pre-1996 (3.2) and declined to 0.9 from 2011-2016. The incidence varied by age and was highest in those aged 20–30 years. Nine percent of the patients had at least one recurrence of HZ and 3% of all cases required hospitalization. At the time of first HZ diagnosis, the median age was 39 years, CD4 count was 459 and VL was 1950 copies. Seventy-seven percent were receiving ART the time of diagnosis with HZ. The authors conclude thatHZ remains a significant problem among people with HIV even in the ART era, and rates are at least 3 times higher than in the general population.

Author’s Commentary: Although seen much less frequently than in the Pre-ART era, HZ remains quite common and in several cohort such as NHS, occurs at younger ages. With the approval of a recombinant subunit vaccine (RZV/Shingrix®), in 2017 more adults >50 years of age are being vaccinated, although the CDC/ACIP has not made any specific recommendations for the use of the vaccine in PLWH. We had been giving RZV to our patients over 50 although currently there is a national shortage of this vaccine. The fact that HZ in PLWH has a high incidence in younger person suggests a waning of the immune responses to varicella zoster virus. This also suggests the need for efficacy and safety studies of RZV in persons less than 50 years old.

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