A 6-month-old male infant born to an HIV-positive mother on antiretroviral therapy (CD4 count >200 cells/µL) presents for routine immunisation. The mother is on undetectable viral load. Which of the following vaccines should be AVOIDED in this child at this visit?

Explanation

## Immunisation in HIV-Exposed Infants ### Clinical Context This is an HIV-exposed but likely uninfected (HEU) infant born to a mother on effective antiretroviral therapy with undetectable viral load. The CD4 count >200 cells/µL indicates adequate maternal immune function. ### Key Point: Live vs Inactivated Vaccines in HEU Infants **OPV is a live attenuated vaccine** and is contraindicated in: - HIV-exposed infants (regardless of infection status) until HIV infection is definitively ruled out - HIV-infected children with CD4 <200 cells/µL (absolute contraindication) **IPV (inactivated polio vaccine)** is the safe alternative for: - All HIV-exposed infants - HIV-infected children at any CD4 count - Provides equivalent protection without risk of vaccine-strain poliovirus shedding ### High-Yield: IAP Recommendations for HEU Infants According to IAP 2023 guidelines, HEU infants should receive: - **IPV instead of OPV** from birth onwards - All other inactivated vaccines (DPT, Hepatitis B, Hib, PCV, Hepatitis A, Typhoid, Japanese encephalitis) as per normal schedule - Live vaccines (MMR, Varicella, Rotavirus) are deferred until HIV infection is excluded (typically by 18 months with two negative virological tests) ### Clinical Pearl Even though this infant has a low risk of being HIV-infected (mother on undetectable viral load), the conservative approach is to avoid OPV until serological confirmation of HIV-negative status is obtained, as vaccine-strain poliovirus can be shed and transmitted to immunocompromised contacts. ### Table: Vaccine Safety in HEU Infants | Vaccine Type | HEU Infant (0–18 mo) | Notes | |---|---|---| | IPV | ✓ Safe | Preferred polio vaccine | | OPV | ✗ Contraindicated | Risk of vaccine-strain shedding | | DPT (inactivated) | ✓ Safe | Standard schedule | | Hepatitis B | ✓ Safe | Standard schedule | | Rotavirus | ✗ Deferred | Live vaccine; defer until HIV ruled out | | MMR | ✗ Deferred | Live vaccine; defer until HIV ruled out | | PCV, Hib | ✓ Safe | Inactivated; standard schedule | ### Mnemonic: LIVE vaccines to DEFER in HEU **LMRV** = Live vaccines (MMR, Rotavirus, Varicella) are deferred until HIV status is confirmed negative.