Abstract
Sir: Doctors Steedman and Macmillan reported a successful (anti-HBs >100 IU/L) hepatitis B vaccination rate of only 31% for new HIV-positive patients in their clinic. 1 Twelve percent defaulted vaccination and 4% were known vaccine non-responders. One way of overcoming vaccination adherence problems and achieving rapid immunity is to use the ultra-rapid (0,1,3 week) schedule. 2 There are currently no published trials on the use of this regimen in HIV although we did report efficacy in a small cohort of patients as a conference poster. 3
This Central Middlesex Hospital HIV unit offers the ultra-rapid course to all HIV-positive patients for whom rapid immunity is important and where adherence to the vaccination schedule could be a problem. We recently audited our results and found that 65 HIV-positive patients had been prescribed the ultra-rapid course of whom 49 received the doses as scheduled and the other 16 received their three doses over a longer period. Of the 49 who completed the ultra-rapid course on time, about half had an undetectable viral load (VL) and were on antiretroviral therapy (ART) (Table 1). Response at six weeks after the third dose was 25/49 (51%) at anti-HBs levels >10 IU/L and 11/49 (22%) for anti-HBs levels >100 IU/L. This response rate compares favourably with published longer vaccination courses, which also achieve anti-HBs levels >10 IU/L in 17–59%. 4–8 Response to vaccination was not statistically related to ART use, CD4 percentage, CD8 count, VL, nor, unlike other studies with CD4 count (Table 1). Vaccine early non-responders were prescribed a repeat ultra-rapid course. The cumulative response rate (anti-HBs >10 IU/L) for those nine HIV-positive patients who have so far received six vaccine doses was 88%. All patients achieving anti-HBs 10–99 IU/L developed levels >100 IU/L after a further booster.
Demographic and clinical markers by response (anti-HBs >10 IU/L)
ART = antiretroviral therapy; VL = viral load
*African or Afro-Caribbean
†Data missing for two patients
In this clinic, which has a preponderance of heterosexual men and women from ethnic minorities (largely sub-Saharan Africa, Table 1), we have therefore shown that early immunity can be achieved using the ultra-rapid course. It is likely that had we waited for one year for the fourth vaccine dose, as recommended in the British National Formulary, 9 more patients would have seroconverted to anti-HBs but many would remain non-immune. We believe that we have shown that by testing for anti-HBs after only three doses of vaccine followed by early repeat vaccination when necessary, ultra-rapid vaccination is an effective strategy in achieving a rapid anti-HBs response in HIV-positive patients.