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Zorluk: Çok zorPreventive Care and Screening

A 35-year-old man comes to the clinic for a routine wellness examination. He was diagnosed with HIV 5 years ago. He is highly adherent to his daily antiretroviral therapy regimen, which consists of bictegravir, emtricitabine, and tenofovir alafenamide. He feels well and reports no fatigue, weight loss, or recent illnesses. He identifies as a man who has sex with men and is in a monogamous relationship. He does not use tobacco, alcohol, or illicit drugs.

His most recent laboratory studies from two weeks ago show a CD4 T-lymphocyte count of 720 cells/mm³ and an undetectable HIV-1 viral load.

A review of his immunization record reveals the following:
- Tetanus, diphtheria, and acellular pertussis (Tdap) vaccine: 1 dose received 4 years ago
- Hepatitis A and B vaccines: completed series 5 years ago; recent serology confirms robust immunity
- Human papillomavirus (HPV) vaccine: completed 3-dose series at age 24
- Quadrivalent meningococcal conjugate vaccine (MenACWY): completed a 2-dose primary series 3 years ago
- 20-valent pneumococcal conjugate vaccine (PCV20): 1 dose received 1 year ago

He had a documented case of chickenpox at age 6. His vital signs are within normal limits, and physical examination shows no abnormalities.

Which of the following is the most appropriate next step in the preventive care of this patient?

  1. Administer recombinant zoster vaccineCevap
  2. B
    Administer 23-valent pneumococcal polysaccharide vaccine
  3. C
    Administer quadrivalent meningococcal conjugate vaccine
  4. D
    Administer a booster dose of the tetanus and diphtheria toxoids (Td) vaccine
  5. E
    Administer live-attenuated varicella vaccine

Cevap

The most appropriate next step is to administer the recombinant zoster vaccine.
The correct answer is to administer the recombinant zoster vaccine. According to the Advisory Committee on Immunization Practices (ACIP), all adults aged 19 years and older with immunocompromising conditions—including HIV infection—should receive a 2-dose series of the recombinant zoster vaccine (RZV) to prevent herpes zoster and postherpetic neuralgia. This patient's HIV diagnosis qualifies him for RZV despite his young age (35) and excellent immune reconstitution (CD4 count of 720 cells/mm³).

Adım Adım Çözüm

1
Classify the patient's risk profile based on his medical history.
The patient is a 35-year-old adult living with HIV.
HIV infection alters routine adult immunization schedules and introduces specific indications, regardless of a well-preserved CD4 count.
2
Evaluate the patient's pneumococcal vaccination status against immunocompromised guidelines.
The patient received PCV20 one year ago and requires no further pneumococcal vaccines.
Current ACIP guidelines for immunocompromised adults dictate either a single dose of PCV20 OR a dose of PCV15 followed by PPSV23. PCV20 acts as a complete regimen.
3
Evaluate the timing for the meningococcal (MenACWY) and tetanus (Td/Tdap) boosters.
Neither booster is due. MenACWY is boosted every 5 years in HIV (due in 2 years), and Tdap is boosted every 10 years (due in 6 years).
Applying the correct chronologic intervals prevents unnecessary over-vaccination.
4
Assess indications for varicella and zoster vaccines based on age and immune status.
The patient is immune to primary varicella (chickenpox history) but requires the recombinant zoster vaccine (RZV).
ACIP guidelines recommend a 2-dose series of RZV for all adults aged 19 years and older who have an immunocompromising condition, including HIV, to prevent herpes zoster (shingles).

Anahtar Kavram

Adult immunization schedules in immunocompromised populations, specifically indications for recombinant zoster vaccine starting at age 19 and pneumococcal/meningococcal sequencing.
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Preventive Care and Screening

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