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Difficulty: HardPreventive Care and Screening

A 58-year-old cisgender male presents to the clinic to establish care. He reports feeling well and has no acute symptoms. His past medical history is notable for HIV infection, diagnosed 10 years ago, and essential hypertension. He is currently maintained on a daily antiretroviral regimen of bictegravir, emtricitabine, and tenofovir alafenamide, with a most recent CD4 count of 520 cells/mm³ and an undetectable viral load. He has a 30-pack-year smoking history but successfully quit 5 years ago. His last preventive health visit was 3 years ago, during which he underwent a screening colonoscopy with normal findings. His vaccination records confirm receipt of a Tdap booster 3 years ago and an inactivated influenza vaccine 2 weeks ago. He has never received any pneumococcal or herpes zoster vaccines. Vital signs and physical examination today are unremarkable.

Which of the following preventive interventions are currently indicated for this patient? (Select all that apply)

  1. Low-dose chest computed tomographyAnswer
  2. 20-valent pneumococcal conjugate vaccine (PCV20)Answer
  3. Recombinant zoster vaccineAnswer
  4. D
    One-time screening abdominal ultrasonography
  5. E
    23-valent pneumococcal polysaccharide vaccine (PPSV23) alone

Answer

The indicated preventive interventions for this patient are low-dose chest computed tomography (LDCT), the 20-valent pneumococcal conjugate vaccine (PCV20), and the recombinant zoster vaccine.
The correct selections represent three distinct guideline-concordant interventions for this patient. First, annual low-dose chest computed tomography is recommended by the USPSTF for adults aged 50 to 80 years with a minimum 20 pack-year smoking history who currently smoke or have quit within the past 15 years. This patient is 58, has a 30 pack-year history, and quit 5 years ago, perfectly meeting the criteria. Second, the Advisory Committee on Immunization Practices (ACIP) recommends that adults aged 19 to 64 years with specific underlying conditions (including HIV) who have not previously received a pneumococcal conjugate vaccine receive either a single dose of PCV20 or a dose of PCV15 followed by a dose of PPSV23. Thus, PCV20 is fully indicated. Finally, the recombinant zoster vaccine is recommended as a 2-dose series for all adults aged 50 and older, as well as for those 19 and older who are immunocompromised. Since this patient is both 58 and has HIV, he has dual indications for this vaccine.

Step-by-Step Solution

1
Evaluate the patient's age and smoking history for cancer screening indications.
The patient is 58 years old, has a 30 pack-year history, and quit 5 years ago.
The USPSTF recommends annual LDCT for lung cancer screening in adults aged 50 to 80 with at least a 20 pack-year smoking history who currently smoke or quit within the past 15 years.
2
Assess immunization needs based on age and comorbid conditions (HIV).
The patient requires protection against pneumococcal disease and herpes zoster.
HIV is an immunocompromising condition that necessitates specific adult vaccinations, and his age (58) provides additional indications for certain vaccines.
3
Determine the correct pneumococcal vaccination sequence for a vaccine-naive adult with HIV.
The patient should receive either PCV20 alone or PCV15 followed by PPSV23.
ACIP guidelines dictate that higher-valent conjugate vaccines should be used as the primary dose for naive adults with high-risk conditions, making PPSV23 alone incorrect.
4
Evaluate indications for abdominal aortic aneurysm (AAA) screening.
AAA screening is not currently indicated.
Although the patient is a male with a history of smoking, the USPSTF age criteria for a one-time screening ultrasound is 65 to 75 years; this patient is 58.

Key Concept

Complex preventive care requires synthesizing age-based screening guidelines with disease-specific immunization protocols, particularly in patients with immunocompromising conditions like HIV.
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Topics

Preventive Care and Screening

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