- Researchers found that shingles was more serious and occurred earlier in people with HIV
- In the Calgary study, hospitalization for shingles cost on average $33,000 per person
- Subsidizing shingles vaccines would likely increase their use and reduce hospitalization costs
Varicella-zoster virus (VZV) causes a common childhood illness called chickenpox. After a child recovers from chickenpox, the virus goes into hiding in nerve cells. Decades later, for reasons that are not clear, the virus can come out of hiding and cause an illness called shingles. This illness is most common in people over the age of 50.
Shingles is a painful condition with rash, blisters and itchy skin usually appearing on one side of the body. Most people recover after one to four weeks. However, in a minority of people, severe pain associated with shingles can persist for months after skin blisters have healed. Shingles can also cause an array of complications. In people with weakened immune systems, shingles can be severe.
Seeking medical consultation early in cases of possible shingles is important because antiviral drugs (famciclovir, valacyclovir) are available. Clinical trials have found that if these drugs are used in early-stage shingles, they can reduce the likelihood of new skin lesions and associated pain.
In Canada and other high-income countries, vaccines are approved that can greatly reduce the risk of shingles. However, they are not widely subsidized.
Shingles and HIV
According to a team of researchers at the University of Calgary, shingles and its complications can cause “substantial” illness, particularly in people with weakened immune systems, including people with HIV. Since the mid-1990s, effective HIV treatment (ART) is more widely available, improving overall health and reducing the risk of many serious infections in people who use ART. However, despite the availability of ART, studies have found that people with HIV are at heightened risk for shingles. Furthermore, shingles appears to occur earlier in people with HIV.
Research in Southern Alberta
The same team of researchers in Calgary have been reviewing medical and laboratory test records of 2,628 people with HIV, focusing on cases of shingles. These records spanned the years 2000 to 2020. The researchers found 38 cases of hospitalization and 138 visits to the emergency department (ED) of a hospital or an urgent care (UC) facility, all as a result of people suffering from shingles. Many cases were in people under the age of 50 and more than 99% had never been immunized against shingles. According to the researchers, 65% were not taking ART at the time of their shingles diagnosis. Nearly a quarter of hospitalizations that occurred in the study arose because of shingles-related issues. The researchers calculated that each person who required hospitalization cost the system about CDN $33,000. These findings underscore the need for subsidizing the cost of a shingles vaccine, particularly for people with HIV.
Researchers analysed health records from the greater Calgary region. The researchers focused on 2,628 people who were tested for exposure to VZV early in their entry to HIV care. A majority (95%) of people had been exposed to the virus in the past; very likely this was due to chickenpox during childhood.
Over the course of the study there were 176 episodes of shingles (and in some cases, shingles-related complications) in 123 people. These 176 episodes (some people required more than one trip to a healthcare facility) led to visits to the emergency room of a hospital or an urgent care clinic.
Of the 176 visits to a healthcare facility because of shingles, 29 people were admitted to a hospital, for a total of 38 hospitalizations (some people required more than one round of hospitalization). Although most visits were for uncomplicated shingles, 25% of visits were for serious complications such an inflammation and/or infection of the brain caused by VZV infection.
Risk factors for shingles
Researchers found that people who required hospitalization (vs. people who did not require hospitalization) were more likely to have the following factors/issues:
- not taking ART – 69%
- a detectable HIV viral load – 76%
- a lower average CD4+ cell count – 210 cells/mm3
Severity of illness, hospitalization and costs
Among people who were hospitalized, the researchers found that those who developed brain-related complications of shingles (encephalitis or meningitis) had similar rates of use of ART and viral suppression as people who did not develop such complications but who also required hospitalization or treatment at an urgent care facility. However, people who did develop brain-related complications tended to have lower CD4+ cell counts—around 130 cells/mm3.
On average, people were hospitalized for eight days.
No one died from shingles-related complications.
Among the 38 people hospitalized, total costs of care averaged $33,000.
Bear in mind
The researchers stated that their findings support advice from the Infectious Diseases Society of America (IDSA)—North America’s premier body of scientists and doctors who study and treat infectious diseases. This body advises that people with HIV be screened for VZV exposure when they enter care and be offered vaccination against shingles.
The researchers found low rates of shingles vaccination in the population studied. They stated that this was due to “the sparsity of public funding for shingles vaccination in Canada, which imposes an additional economic burden on an already socially vulnerable population.”
The researchers also stated: “We noted that not taking ART, having a detectable HIV viral load, and having a lower CD4+ count are major risk factors for both VZV-related hospitalizations and emergency department/urgent care clinic visits. A gradient for these factors was noted, as worse markers [lower CD4+ cell counts, detectable viral load] were related to increased risk of hospitalizations over an ED/UC visit.” The researchers found that there was a relatively large proportion of people who were not on ART. They were concerned that there may be barriers that affected people’s ability to take and remain on ART and that these same barriers may also affect readiness to get vaccinated against shingles.
An important point made by the researchers is that all cases of admission to hospital or urgent care centre in this study were due to reactivation of VZV; that is, the virus had come out of latency or hiding. No cases of shingles were caused by new infections of VZV.
The researchers noted that their study documented a high risk for shingles-related illness among people with HIV. For the most part, these people were relatively young — 41 years. In contrast, the researchers found that in studies of HIV-negative people the average age at which shingles occurs is 59 years. Based on the findings in their study, the researchers encouraged that early initiation of the shingles vaccine be considered for people with HIV.
The researchers underscored that in their study health systems and ultimately governments would have saved $1.2 million in costs if people with HIV had been vaccinated against shingles.
For the future
As mentioned earlier in this CATIE News bulletin, shingles can cause severe pain in some people even after skin blisters have healed. The present study did not assess the costs of long-term disability arising from shingles-related issues. A different study could take up that issue in the future. However, the 20-year span of their analysis has documented the earlier onset of shingles and its significant impact on the health of people living with HIV as well as the costs to the system. Although the present study does not calculate cost-effectiveness of shingles vaccination, it does make a strong case for the need for such vaccination among people with HIV and the cost savings that would ensue.
—Sean R. Hosein
Herpes zoster (shingles) vaccine: Canadian Immunization Guide – Government of Canada
Shingles vaccine – Government of Quebec
Shingles – BC Centre for Disease Control
Comparing health outcomes among people with HIV in urban and non-urban Alberta – CATIE News
- Whitley RJ. Chapter 193. Varicella-zoster virus infection. In: Loscalzo J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Jameson JL. Harrison’s Principles of Internal Medicine. 21st Edition. New York: McGraw-Hill; 2022.
- Zou J, Krentz HB, Lang R, et al. Seropositivity, risks, and morbidity from varicella-zoster virus infections in an adult PWH cohort from 2000-2020. Open Forum Infectious Diseases. 2022 Aug 9;9(8):ofac395.
- John AR, Canaday DH. Herpes zoster in the older adult. Infectious Disease Clinics of North America. 2017 Dec;31(4):811-826.
- Arora A, Mendoza N, Brantley J, et al. Double-blind study comparing 2 dosages of valacyclovir hydrochloride for the treatment of uncomplicated herpes zoster in immunocompromised patients 18 years of age and older. Journal of Infectious Diseases. 2008 May 1;197(9):1289-95.
- Marra F, Chong M, Najafzadeh M. Increasing incidence associated with herpes zoster infection in British Columbia, Canada. BMC Infect Diseases. 2016 Oct 20;16(1):589.
- López-Fauqued M, Campora L, Delannois F, et al. Safety profile of the adjuvanted recombinant zoster vaccine: Pooled analysis of two large, randomised phase 3 trials. Vaccine. 2019 Apr 24;37(18):2482-2493.