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Maria C. Rodriguez-Barradas, Joseph Goulet, Sheldon Brown, Matthew Bidwell Goetz, David Rimland, Michael S. Simberkoff, Kristina Crothers, Amy C. Justice, Reply to Sogaard et al., Clinical Infectious Diseases, Volume 47, Issue 2, 15 July 2008, Pages 295–296, https://doi.org/10.1086/589581
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To the Editor—We appreciate the comments by Sogaard et al. [1]. They suggest that we may have overestimated the efficacy of the 23-valent pneumococcal polysaccharide vaccine (PPV) among HIV-infected patients, because current guidelines do not actively recommend that PPV be administered to persons with CD4+ cell counts <200 cells/µL (who are more likely to have an episode of pneumonia) and because we did not use time-varying CD4+ cell count measurements in our models. These are interesting points to which we are pleased to respond.
If persons with lower CD4+ cell counts were less likely to have received PPV, our analyses would have been biased. However, CD4+ cell count at baseline was not associated with a history of PPV vaccination (67% of patients with CD4+ cell count <200 cells/µL were vaccinated, and 69% of patients with CD4+ cell counts ⩾200 cells/µL were vaccinated; P = .67). Specifically, current guidelines recommend that all patients with a CD4+ cell count ⩾200 cells/µL receive PPV and that PPV vaccination be considered for those with a CD4+ cell count <200 cells/µL [2]. Other guidelines recommend vaccination of all HIV-infected patients when a diagnosis of HIV infection is determined [3]. An informal survey conducted several years ago among HIV clinicians at Veterans Affairs hospitals revealed that there was not a consistent policy among the different Veterans Affairs HIV clinics or among different practitioners within a clinic regarding these recommendations (M.C.R.-B., unpublished observations). Thus, we have no evidence that patients with higher CD4+ cell counts were more likely to receive PPV. Nevertheless, baseline CD4+ cell count was related to risk of pneumonia; 46% of patients with a CD4+ cell count <200 cells/µL experienced a pneumonia event, and only 7% of patients with a CD4+ cell count ⩾200 cells/µL experienced such an event (P < .001). This is consistent with data from many other observational studies [4].
