Herpes zoster vaccination in people living with HIV: from evidence to implementation – A narrative review

Herpes zoster (HZ) remains a significant, preventable cause of morbidity among people living with HIV (PLWH), who face increased risks of HZ, recurrence, and complications despite effective antiretroviral therapy. The recombinant zoster vaccine (RZV), a non-live, adjuvanted vaccine, is currently the preferred strategy for HZ prevention in immunocompromised adults. This narrative review synthesizes the evidence on the burden and pathogenesis of HZ in PLWH, RZV immunogenicity and safety, present vaccination recommendations, clinical considerations, and implementation challenges, with particular emphasis on the Asia-Pacific region. Available evidence indicates that RZV induces robust humoral and cellular immune responses and has a favorable safety profile in PLWH; however, HIV-specific evidence regarding clinical effectiveness, long-term durability of protection, and optimal timing of vaccination in the setting of advanced immunosuppression remains limited. International guidelines consistently recommend a two-dose RZV series for adults with HIV, without requiring a specific CD4+ T-cell threshold or virological suppression. Nevertheless, vaccine uptake remains constrained by cost, limited availability, inadequate patient and healthcare-provider awareness, vaccine hesitancy, and fragmented vaccination services. Future research should prioritize real-world effectiveness, durability of protection, cost-effectiveness, and determinants of vaccine acceptance, including behavioral factors, such as perceived susceptibility, perceived benefits, and perceived barriers. Integrating RZV into routine HIV care and strengthening implementation strategies, particularly across the Asia-Pacific region and other resourcelimited settings, will be critical to translating guideline recommendations into equitable vaccination coverage and reducing HZ-related morbidity among PLWH.