Stay well this winter

As the Winter months approach the activity of viruses that cause colds and flu start to increase as do bacterial infections that cause chest infections. This Winter coronavirus poses an additional risk of illness. Whilst a vaccine is now available for coronavirus this will take many months to roll-out across the UK. Taking every precaution to avoid becoming unwell during this Winter has possibly never been as important.

Aside from physical illness during the Winter months it’s becoming increasingly important to look after our emotional wellbeing and mental health. The coronavirus pandemic has resulted in people feeling very isolated, lonely and there are growing worries about job security.

Seasonal flu vaccination

Influenza is a relatively mild illness for the majority of people, but it can be very serious and result in people losing their life. It’s estimated that over a typical Winter period there are 10,000 or more deaths linked to seasonal flu. Having the flu vaccination is a good preventative step, which could be really important this year as there is the added complication of coronavirus.

Who should have the flu vaccination?
The British HIV Association (BHIVA) recommend everyone living with HIV should have an annual flu vaccination regardless of being on treatment or CD4 cell count. Whilst we know vaccines aren’t 100% effective for many people who get flu the symptoms and duration of illness is reduced when they’ve had the flu vaccination.

Where can I get the flu vaccination?
There are different arrangements in place across the UK when it comes to HIV clinics offering the flu vaccination. All GP’s, midwife services and many high street pharmacies provide a vaccination service. In England, if your GP practice isn’t aware that you are living with HIV you won’t be contacted and invited to get a free flu vaccination.

High street pharmacies offer a free flu vaccination service for those who are eligible and a paid service for those who don’t fall under the free NHS vaccination programme. If you are uncomfortable sharing your HIV status to receive the free vaccination, you can use the paid service which is approximately £13 this year.

Can I still get flu after having the vaccination?
It is possible to get flu after having the vaccination, particularly in the first few weeks after having it. This is because it can take up to 3 weeks for antibodies to form and protect you from flu. We recommend you have your flu vaccination in early to mid-October when levels of flu virus are low.

Pneumonia vaccination

Pneumonia is caused by a bacterial infection of the lungs which become inflamed (one side or both) making it difficult to breath properly and for the body to get enough oxygen. Coronavirus can cause viral pneumonia, so it’s important to get your symptoms checked out to make sure your symptoms are correctly diagnosed and effective treatment given.

Who should have the pneumonia vaccination?
BHIVA vaccination guidelines and the Department of Health Green Book (vaccination bible) recommend people living with HIV receive the pneumonia vaccination. There is however a difference in the type of vaccine recommended for people living with HIV.

Where can I get the pneumonia vaccination?
GP’s provide the pneumonia vaccination free of charge for those who are eligible. HIV is an eligible health condition along with some other long-term health conditions. Some high street pharmacies also provide the pneumonia vaccination, but it costs around £75, which is pretty expensive.

Do I have to get the pneumonia vaccination every year?
The short answer is no. The antibodies produced by the vaccination can provide effective cover for up to 10 years, although for some people living with HIV a booster may need to be given after five years.

Which of the vaccines should I have?
The BHIVA guidelines recommend the use of a vaccine called PCV-13 (Prevnar-13), which is usually used for children. The Department of Health Green Book recommends the use of the vaccine called PPV-23 (Pneumococcal Polysaccharide Vaccine) which is used for adults over the age of 65 or those who have another long-term health condition which makes them eligible regardless of their age.

The PPV-23 vaccination offers protection against 23 different bacterial strains, whereas Prevnar-13 offers protection against 13 different strains. One of the benefits of using Prevnar-13 is it results in a better initial response than PPV-23.

You can have either of the vaccinations, although it is likely the adult PPV-23 vaccine will be more readily available, particularly in high street pharmacies. It is also possible to have both vaccinations but there needs to be a period of at least 3 months between having them. The evidence on the benefit of having both is limited and not recommended by BHIVA at this time.

Can I still get pneumonia despite having the vaccination?
You can still get pneumonia after having the vaccination, particularly in the first few weeks as it can take time for the body to produce antibodies. If you’re unfortunate enough to get pneumonia, it’s likely the severity of symptoms and length of illness may be reduced as the immune system will have been ‘primed’ to fight the infection.

Coronavirus (COVID-19) vaccination

We now have coronavirus vaccines that are safe and effective for people living with HIV as well as the general population. The vaccine trials have shown that people who have the vaccination are less likely to become severely unwell, be admitted to hospital or die from COVID-19 illness. It will take several months for enough people to get vaccinated to reduce the numbers of new cases and to stop the spread of coronavirus. In the meantime, it is important to continue to take all the necessary precautions to prevent the spread of coronavirus and to keep up to date with and National and local restrictions that are in place.

Who should have the coronavirus vaccination?
The British HIV Association (BHIVA) recommend people living with HIV should have the coronavirus vaccination. This advice is echoed in the Department of Health Green Book (vaccination bible).

The coronavirus vaccines do not include ‘live’ coronavirus virus and therefore having the vaccination will not give you coronavirus. Each of the current vaccinations work in slightly different ways and have been found to be highly effective and well tolerated. There have been isolated cases of allergic reaction with the Pfizer BioNTec vaccine. As with all vaccinations it’s important you let the healthcare professional know if you have experienced any allergic reactions previously and have been advised to carry an Epipen (or similar) to use in the event of a severe allergic event.

When will I be able to get the coronavirus vaccination?
The Government has set out priority groups (1 to 9) as to who should get the coronavirus vaccination first. Priority group 1 is focused on those most vulnerable to getting coronavirus or severe COVID-19 illness. People living with HIV who are stable on treatment and have a CD4 cell count above 200 have been placed in priority group 6. People living with HIV who are extremely clinically vulnerable have been placed in priority group 4 and are expected to receive the vaccine by mid-February if the roll-out goes according to plan.

Will I need to get the coronavirus vaccination every year?
The short answer is we just don’t know! It is expected that for some people living with HIV the immune response produced by the vaccination my not be as strong as that seen in the general population. This is often the case with other vaccinations where dosage, frequency of vaccination and booster doses are given to people living with HIV.

Will I have a choice of the type of vaccine I have?
It is expected the availability of the different vaccines will determine which one you will receive. We don’t yet know if a particular vaccine will be better for people living with HIV. Other factors such as age, ethnicity or other long-term health conditions may also determine which vaccine will be most suitable when more data becomes available.

Can I still get coronavirus despite having the vaccination?
The coronavirus vaccination requires 2 jabs given up to 12 weeks apart. It is expected the first jab will provide high levels of immunity, although it can take a few weeks for this to fully develop. It is still possible to get coronavirus after having the first jab, but it is very likely any resulting illness will be less severe and the duration of symptoms reduced. Like all vaccinations a small proportion of individuals won’t be protected so it’s still possible to get coronavirus after having both jabs.

Will my level of immunity to coronavirus be checked?
At this stage of the vaccination programme it’s not clear if levels of immunity will be checked for people living with HIV. It may well be that as with hepatitis B levels of immunity are checked annually for people living with HIV.

Will coronavirus restrictions still apply once I’ve had both jabs?
The short answer is yes! We will need to follow all the current guidance until enough people have received the vaccination and new case levels remain low.

Vitamin D supplements

Vitamin D is needed for the regulation of calcium and phosphate in the body, which in turn helps maintain bone, teeth and muscle health. It is also important for the regulation or some hormones, and is associated with thyroid function, changes in oestrogen in women and testosterone in men.

More recently it has been suggested that vitamin D may help reduce the health risk associated with coronavirus. At present there isn’t sufficient evidence to support this view, but you can take a vitamin D supplement to keep your bones and muscles healthy, particularly in the Winter months (see below).

During the Spring and Summer months most of the vitamin D the body requires is made by the effect of sunlight on the skin. Foods rich in vitamin D are also an important source, although it can be difficult to get enough vitamin D from diet alone.

Some studies have shown up to 85% of people living with HIV have low levels or a severe deficiency of vitamin D. It is thought HIV related inflammation may interfere with ability of the liver and kidneys to produce the active form of vitamin D known as calcitriol.

Vitamin D Supplementation is sometimes recommended for people living with HIV particularly where there are concerns about bone health, or other symptoms such as tiredness, low mood, depression and weight gain.

Vitamin D supplementation is more important between October and March as daylight hours are shortened and therefore less vitamin D is produced by the action of light on the skin. Public Health England recommend adults take a daily supplement which includes 10 micrograms (400 international units). If you are using a supplement that contains minerals (calcium, magnesium, zinc, iron, aluminium) it’s important to check for any interactions with your HIV medication and allow for a sufficient time period between taking your medication and any supplements.

As a general rule, vitamin D isn’t usually monitored as part of the routine blood monitoring for people living with HIV. You can ask your clinic to run a test, but increasingly clinic teams will refer you to your GP to get the test.

Where vitamin D levels are found to be low or deficient a high dose of around 20,000 international units can be prescribed for a period of time, with a lower maintenance dose equivalent to 20,000 international units over a month.

Seasonal affective disorder (SAD)

SAD is a seasonal disorder which can lead to the development of low mood, depression, lack of energy, tiredness, sleeping for longer than usual and craving carbohydrate rich foods, which can in turn lead to weight gain. SAD is much more common during the Autumn and Winter months when the daylight hours are shortened, and we stay indoors more often.

It’s not entirely clear what causes SAD symptoms, and there is a possibly a genetic link as it seems to run in families. It’s thought that a lack of sunlight has an impact on a part of the brain called the hypothalamus which may affect the production of hormones such as melatonin (regulates sleep) and serotonin (helps regulate mood, appetite and sleep). The regulation of our internal body clock (circadian rhythm) is dependent on sunlight and is responsible for the time we wake up which also regulates other body functions.

We know that many people living with HIV experience periods of low mood and depression and it’s possible that the symptoms of SAD add to these feelings. Many people feel down or experience the ‘Winter blues’ which can become debilitating, so it’s important to get in touch with your GP if you think you may find the Winter months particularly difficult.

Changes in lifestyle are one of the key areas to help ease the symptoms of SAD. Try to get as much natural sunlight as possible, exercising regularly and manage your stress levels. Light therapy can also be helpful although there is a need to purchase a specially designed SAD lamp which ensures the concentration of light provided is sufficient to simulate the hypothalamus. A lamp that emits 10,000 lumens (or more) is required to be effective.

Other approaches include talking therapies, particularly cognitive behavioural therapy (CBT). Antidepressant medicines can also be used to help ease low mood and depression ideally supported by some form of talking therapy or counselling.