2023-A Prospective Immunogenicity Study of a Quadrivalent Inactivated Influenza Vaccine among persons with HIV with Different Levels of CD4 Cell Count

Downloaded from http://journals.lww.com/jaids by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A 1 WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/07/2023 JAIDS Journal of Acquired Immune Deficiency Syndromes Publish Ahead of Print DOI: 10.1097/QAI.0000000000003186 A Prospective Immunogenicity Study of a Quadrivalent Inactivated Influenza Vaccine among persons with HIV with Different Levels of CD4 Cell Count Suparerk Satanon, M.D.1, Sasisopin Kiertiburanakul, M.D., M.H.S.2, Kobporn Boonnak, Ph.D.3, Jackrapong Bruminhent, M.D.2,* 1Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand 2Division of Infectious Diseases, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand 3Department of Immunology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand *Corresponding author Jackrapong Bruminhent, M.D Division of Infectious Diseases, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand 270 Rama VI Road, Ratchatewi, Bangkok, 10400, Thailand Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

2 Email: [email protected] Downloaded from http://journals.lww.com/jaids by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A Short title: Immunogenicity of QIIV in HIV WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/07/2023 The authors report no conflicts of interest related to this work. Abstract Introduction: Data regarding the immunogenicity of a quadrivalent inactivated influenza vaccine (IIV4) among persons with HIV with different levels of CD4 cell count is limited. Here, we report the immunogenicity of IIV4 in persons with HIV with different CD4 cell count levels by determining seroprotection (SP) and seroconversion (SC) rate following vaccination. Method: Persons with HIV were prospectively recruited to receive IIV4 (season 2021) between November 2021 and January 2022. Hemagglutination inhibition (HAI) titers were assessed before and at 28 days after vaccination and classified as SP or SC with comparison of characteristic between CD4 cell count >350 cells/mm3 group and CD4 cell count ≤350 cells/mm3. Result: A total of 70 persons with HIV received the IIV4. The mean (SD) age was 48 (9) years, and 64% were male. The majority (74%) were maintained on an NNRTI-based regimen with an undetectable HIV viral load (100%). There was a significantly greater proportion of persons with HIV who achieved SP against A/Hong Kong/2571/2019-like virus (H3N2) variant in those with CD4 cell count >350 cells/mm3 compared to those with CD4 cell count ≤350 cells/mm3 (98.3% Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Downloaded from http://journals.lww.com/jaids by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A 3 WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/07/2023 vs 72.3%), RR 1.35 (95% CI 1.13-1.61, p=0.011). Furthermore, the participants with CD4 cell count >350 cells/mm3 were significantly more likely to achieve SP against B/Phuket/287/2013 strain (98.3% vs 72.3%, RR 1.35 (95% CI 1.13-1.61, p=0.011). Conclusion: Persons with HIV with greater CD4 cell count could achieve a higher chance of SP against B/Phuket/287/2013 and A/Hong Kong/2571/2019-like virus (H3N2) strains following IIV4 vaccination. Therefore, new strategies should be investigated and offered to those with low CD4 cell counts. Keywords: AIDS; influenza vaccine; immunogenicity; CD4 cell count; seroprotection; seroconversion Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Downloaded from http://journals.lww.com/jaids by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A 4 WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/07/2023 Introduction Influenza virus is an RNA virus causing a contagious respiratory illness and causes worldwide public health problems. Influenza viruses commonly infect the nose, throat, and sometimes the lung, causing mild illness to a severe form and sometimes leading to mortality, especially in an immunocompromised patient. Persons with Human immunodeficiency virus (HIV) are at increased risk of complications from influenza and prolonged symptoms, and hospital stay.1 The disease could potentially be complicated to pneumonia and result in death.2 Therefore, the influenza vaccine is highly recommended for persons with HIV, especially to reduce the impact of respiratory illnesses during the coronavirus disease 2019 (COVID-19) pandemic.2 Although the influenza vaccine is highly recommended for persons with HIV, the immunocompromised condition could prevent adequate antibody response.3,4 Persons with HIV with lower CD4 cell count tend to have a less immunological response to immunization as shown in the studies of monovalent and trivalent influenza vaccine.2 In addition, data regarding the immunogenicity of a quadrivalent inactivated influenza vaccine (IIV4) among persons with HIV with different levels of CD4 cell count is limited.5,6 The primary objective is to investigate immunogenicity in persons with HIV with different levels of CD4 cell count, focused on the rate of seroprotection (SP) and seroconversion (SC) for each influenza virus strain after influenza vaccination. The secondary objective is to assess factors with inadequate antibody response. Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Downloaded from http://journals.lww.com/jaids by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A 5 WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/07/2023 Methods We conducted a prospective study between November 2021 and January 2022 at an outpatient clinic at Ramathibodi Hospital, Bangkok, Thailand. We included all adult (>18 years old) persons with HIV who have been maintained on antiretroviral therapy (ART) for at least 6 months with undetectable viral load (HIV viral load <40 copies/ml). Patients with moderate to severe illness, a history of severe allergic reaction to influenza vaccine or receiving treatment for opportunistic infection were excluded. Baseline characteristics including age, sex, body mass index (BMI), comorbidities, and HIV-related characteristics (e.g., CD4 cell count, antiretroviral regimen, and HIV viral load) were collected. Quadrivalent Inactivated Influenza Vaccine One dose of quadrivalent inactivated influenza vaccine (IIV4): FluQuadriTM (Sanofi Pasteur) season 2021 was used for intramuscular vaccination. The vaccines contained 15 µg of HA per strain of A/Victoria/2570/2019 (H1N1)pdm09-like virus, A/Hong Kong/2571/2019-like virus (H3N2), B/Phuket/287/2013, and B/Washington/02/2019. Influenza Antibody Titers Antibody titer were determined for four influenza strains A/Victoria/2570/2019 (H1N1)pdm09-like virus, A/Hong Kong/2571/ 2019-like virus (H3N2), B/Phuket/287/2013, and B/Washington/02/2019 before vaccination and 28 days after vaccination by hemagglutination inhibition (HAI) assay. Blood samples were taken to assess the immune response to vaccination pre-vaccination and post-vaccination at 28 days. Serum was separated and stored at -20°C until analysis. Antibody titers were determined by a HAI assay. Serum samples were tested against A/Victoria/2570/2019 (H1N1)pdm09-like virus, A/Hong Kong/2571/2019-like virus (H3N2), Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Downloaded from http://journals.lww.com/jaids by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A 6 WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/07/2023 B/Phuket/287/2013, and B/Washington/02/2019 for the 2021 season. Briefly, serum samples were treated with receptor-destroying enzyme (RDE; Denka Seiken, Tokyo, Japan): 300 µL of RDE was added to 25 µL of serum and incubated overnight at 37°C, followed by adsorption with test red blood cells and heat inactivation to eliminate nonspecific inhibitors and nonspecific agglutinators. The treated serum was then serially diluted, and eight hemagglutinations (HA) units/50 µl of the virus was added. The mixture was then incubated at 25°C for 30 minutes. Inhibition of hemagglutination determined after incubating with 0.5% goose erythrocytes (provided by National Laboratory Animal Center, Mahidol University) for H1N1 and influenza B, and 0.75% guinea pig red blood cells (provided by National Laboratory Animal Center, Mahidol University) for H3N2 at 25°C for 30 minutes. HI titers were recorded as the inverse of the highest antibody dilution that inhibited hemagglutination. Seroprotection (SP) was defined as HAI titer ≥1:40. Seroconversion (SC) is classified as either HI titer >1:40 if pre-vaccination <1:10 or greater than a 4-fold increase if pre-vaccination ≥1:10. Geometric mean titer (GMT) was an average antibody titer for a group of subjects. Statistical Analyses The participants were divided into two groups, including those with CD4 cell counts <350 and >350 cells/mm3. Categorical and continuous variables were reported as absolute numbers, frequencies, or medians with interquartile range (IQR). The chi-square test and Fisher’s exact test were performed to compare categorical variables as appropriate. The Mann– Whitney U test and Wilcoxon signed-rank test were performed to compare continuous variables between and within the groups, respectively. Binary regression, primarily CD4 cell counts, was performed to determine factors associated with seroconversion immunogenicity. Statistical Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Downloaded from http://journals.lww.com/jaids by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A 7 WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/07/2023 analyses were performed with Stata statistical software, version 15 (StataCorp, LLC; College Station, TX, USA). P value of <0.05 is considered statistically significant. Results Demographic Data A total of 85 persons with HIV were retrieved during the study. Among those, two and 13 patients were excluded due to viral load >40 copies/mL and lost of a follow-up appointment as protocol, respectively. There were 70 persons with HIV completed the protocol with CD4 cell counts ≤350 cells/mm3 (n=11) and CD4 cell counts >350 cells/mm3 (n=59) (Figure 1). The majority of the population was male (64%), the mean (SD) of age was 46.1(8.7) years, the mean (SD) of absolute lymphocyte count and CD4 was 2,320 (723) and 601.5 (265) cells/mm3, respectively. Non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimen was the majority of antiretroviral therapy regimen (74.2%). The demographics and clinical characteristics of two CD4 cell counts group are compared in Table 1. Among those whose CD4 cell counts ≤350 cells/mm3, 82% were male with a mean (SD) age of 48 (9) years and for those whose CD4 cell counts >350 cells/mm3, 61% were male with a mean (SD) age of 46 (9) years. Significant difference in white blood cell count (WBC) and absolute lymphocyte count(ALC) were found between the two groups. The mean (SD) of WBC was lower in the ≤350 cells/mm3 group than in the >350 cells/mm3 group [5561.8 (1367.5) vs 6551.9 (1514.6) p=0.048], similarly in ALC, mean(SD) of ALC was lower in CD4 cell counts ≤350 cells/mm3 group compared to those in CD4 cell counts >350 cells/mm3 [1826.5 (666.2) vs 2412.5 (700.9) p=0.013] (Table 1). Geometric Mean Titer Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Downloaded from http://journals.lww.com/jaids by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A 8 WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/07/2023 The mean (SD) pre-vaccination GMT of A/Victoria/2570/2019 (H1N1)pdm09-like virus was higher in the ≤350 cells/mm3 group than in the >350 cells/mm3 group [725 (1,776) vs 145 (216) p=0.030]. Similarly, the mean (SD) pre-vaccination GMT of A/Hong Kong/2571/2019-like virus (H3N2) was higher in the ≤350 cells/mm3 group than in the >350 cells/mm3 group [534 (917) vs. 128 (186) p=0.004]. However, no significant differences were found between the groups in the mean post-vaccination GMT for all variants. The ratios between the post and pre- IIV4 vaccination GMTs are presented in Figure 2. Seroconversion and seroprotection The rate of SP and SC compared between two groups are shown by each strain in Table 2 and Figure 3. SP rate against A/Hong Kong/2571/2019-like virus (H3N2) at day 28 was higher in group CD4 cell counts >350 cells/mm3 compared to those with CD4 cell counts ≤350 cells/mm3 (98.3% vs 72.3%). CD4 count > 350 cells/mm3 was the only factor significantly associated with SP in univariate analysis, relative risk (RR) 1.35 (95% CI 1.13-1.61, p=0.011). Similarly, in B/Phuket/287/2013 strain, SP rate was higher in group CD4 cell count >350 cells/mm3 compared to those with CD4 cell counts ≤350 cells/mm3 (98.3% vs 72.3%) and CD4 count > 350 cells/mm3 was also the only factor associated with SP in univariate analysis, RR 1.35 (95% CI 1.13-1.61, p=0.011). There was no significant difference in the SP rate of A/Victoria/2570/2019 (H1N1)pdm09-like virus and B/Washington/02/2019. For SC, there was no significant difference in terms of immunity against all variants between the two groups. For secondary outcomes, characteristics of persons with HIV with SP (SP group) and those without SP (non-SP group) were compared (Table 3-6). Mean age in non-SP group was older than SP group in A/Victoria/2570/2019 (H1N1)pdm09-like virus [51.8 (6.1) vs. 45.1 (8.8) p=0.017] and B/Washington/02/2019 [51.6 (6.3) vs. 45.2 (8.8), p=0.031]. The percentage Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Downloaded from http://journals.lww.com/jaids by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A 9 WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/07/2023 of protease inhibitor-based regimen was significantly higher in the no seroconversion group compared to those in the seroconversion group of A/Victoria/2570/2019 (H1N1)pdm09-like virus (21% vs. 2% p=0.016) and B/Washington/02/2019 (21% vs. 4%, p=0.042). For A/Hong Kong/2571/ 2019-like virus (H3N2) strain, those without seroprotection were more likely to receive the COVID-19 vaccine further away from IIV4 than those with seroprotection (65.1 vs. 45.6 days, p=0.015). There were no factors associated with seroconversion against A/Hong Kong/2571/ 2019-like virus (H3N2) and B/Phuket/287/2013 strains. Discussion Our study investigated an IIV4 immunogenicity in persons with HIV with different CD4 cell counts. There was no significant difference in SP rate after IIV4 in persons with HIV with different CD4 cell counts. However, the SC rate decreases, and GMT tend to be lowest in those with a lower CD4 count (<350 cells/mm3). The data from this study can be applied for guiding personalized influenza immunization for persons with HIV based on their immunological status. A single dose of monovalent 2009 influenza A (H1N1) vaccine resulted in poor immunogenicity among Thai persons with HIV (median CD4 cell count of 374 cells/mm3) showed that only 42% and 30% of the participants with HIV were seroconverted and seroprotected, respectively.6 This was interpreted as 42% and 58% less than those with normal immune status.6 Although we did not compare to immunocompetent individuals in our study, we stratified the participants into high and low immunologic status using a cut-off of 350 cells/mm3. A recent study evaluating immunogenicity among healthy adults receiving QIV revealed a greater geometric mean titer than persons with HIV in our cohort. However, the strain in the vaccine and the method to assess the titer may vary across the studies.7 Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Downloaded from http://journals.lww.com/jaids by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A 10 WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/07/2023 Since the antibody response to vaccination is mainly dependent upon CD4 cell function, persons with HIV with low CD4 count would likely be at risk of poor immune response following immunization. An association of low CD4 cell count and inadequate immune responses after influenza vaccination have been reported in the literatures.8-10 Since our persons with HIV were having positive antibody to influenza virus at baseline from either previous vaccination or infection, therefore a significance of an increasing trend of HAI after vaccination was not achieved. This was supported by a study which also did not result in difference in anti- H1 and anti-H3 antibody responses between those with CD4 count greater or less than 200 cells/mm3. On the other hand, a significant difference was more pronounced among those with negative antibody before vaccination.9 In terms of seroprotection, older age is well-known as a predictor of suboptimal immunogenicity after immunization. A study revealed HIV-naive and infected women with aging may compromise influenza vaccine-induced antibody response.11 Immune activation associated with HIV infection and impaired peripheral T follicular helper cells function heighten deficiencies in antibody responses to influenza vaccine in older individuals.12 Furthermore, we also revealed persons with HIV who were maintained on protease inhibitor-based regimen were more likely to develop poor immune responses compared to other regimens . This association has never been reported but maybe from protease inhibitor-based regimen frequently use in persons who HIV-infected for long time and may developed drug resistant strain causing poor immune response however, the mechanism of action of anti-retroviral agents should be focused. Those with protease inhibitor-based regimen could be more likely to pertain drug-resistant HIV infection which could reflect in poor immune recovery. However, these associations did not show against A/Hong Kong/2571/ 2019-like virus (H3N2) and B/Phuket/287/2013 strains which Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Downloaded from http://journals.lww.com/jaids by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A 11 WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/07/2023 could be less circulated in our community. Another study investigated seroprotection rates following high-dose inactive influenza vaccination were significantly higher in the high-dose group for the H1N1 influenza A and influenza B but not for H3N2 influenza A.13 Furthermore, we found that those with seroprotection tend to receive the COVID-19 vaccine close to IIV4. Our data also support a co-administration of the influenza vaccine and COVID-19 vaccine regardless of the interval since there is no significant difference between the interval of those two vaccines and immunogenicity. Additionally, previous studies revealed other variables related to the vaccine response, including innate immune endotypes and opportunistic infections such as cytomegalovirus.14, 15 The strength of this study is that one of the few studies investigated the immunogenicity of IIV4 among persons with HIV graded by CD4 count. This study could provide immunogenicity based on their immune status. CD4 cell count of 350 cells/mm3 and greater could be proposed as an appropriate cut-off point to initiate immunization in this population since CD4 is an essential component for cell-mediated immune responses to immunization due to its property as an essential core for memory B cell production which could offer prolonged immunogenicity.16 Furthermore, we also assessed immunogenicity using the HI assay, which is the gold-standard assay of antibody titers against HA, based on erythrocyte agglutination due to the ability of antibodies that specifically recognize HA to inhibit the binding of viral surface protein HA to sialic acid sites on the surface of red blood cells.17 However, this study is also limited in sample size due to the COVID-19 pandemic, resulting in decreased study power. Second, this data may not be able to postulate for those with a detectable viral load since those were not included in our study. Third, some patients could have been vaccinated with the influenza vaccine in the past or previously infected. These could limit a significant change in Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Downloaded from http://journals.lww.com/jaids by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A 12 WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/07/2023 their immunogenicity. Additionally, only humoral immunity was explored, and cell-mediated immunity is of interest to be further explored to assess whole immune responses. In conclusion, persons with HIV with greater CD4 cell counts could achieve a higher chance of SP against particular strains following IIV4 vaccination. Therefore, new strategies should be investigated and offered to those with low CD4 cell counts to better respond to influenza immunization. Individuals with weaker immune function could be benefitted from alternative vaccine strategies. Competing interests No conflict of interest declared. Author contributions ST: conception and design of the study, acquisition of data, analysis and interpretation of the data, drafting the article, revising the article, final approval of the version to be submitted. SK: analysis and interpretation of the data, revising the article, final approval of the version to be submitted. KB: analysis and interpretation of the data, final approval of the version to be submitted (supported). JB: conception and design of the study, acquisition of data, analysis and interpretation of the data, drafting the article, revising the article, final approval of the version to be submitted Acknowledgement We would like to specially thank nursing staffs and coordinators at the Division of Infectious Diseases, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Downloaded from http://journals.lww.com/jaids by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A 13 WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/07/2023 Funding This work was supported by Faculty of medicine Ramathibodi hospital, Mahidol University, Bangkok, Thailand (grant number RF_64049). Ethics approval The study protocol was approved by the Human Research Ethics Committee of the Faculty of Medicine at Ramathibodi Hospital, Mahidol University, Bangkok, Thailand. (approval number: COA. MURA2020/1430). All patients signed a consent form prior to enrollment. Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Downloaded from http://journals.lww.com/jaids by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A 14 WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/07/2023 References 1. Sheth AN, Althoff KN, Brooks JT. Influenza susceptibility, severity, and shedding in HIV- infected adults: a review of the literature. Clin Infect Dis 2011;52:219-27. 2. Onorato IM. National Center for HIV, STD and TB Prevention November 22, 2004. 3. Book of vaccination and immunization. Department of disease control. Ministry of public health of Thailand 2562 4. Interim Guidance for Routine and Influenza Immunization Services During the COVID-19 Pandemic [Update 2021 June 06 ;cited 2022 March 30].Available from : https://www.cdc.gov/vaccines/pandemic-guidance/index.html . 5. Zanetti AR, Amendola A, Besana S, Boschini A, Tanzi E. Safety and immunogenicity of influenza vaccination in individuals infected with HIV. Vaccine 2002;20 Suppl 5:B29-32. 6. Watcharananan SP, Thakkinstian A, Srichunrasmee C, Chuntratita W, Sumethkul V. Comparison of the immunogenicity of a monovalent influenza A/H1N1 2009 vaccine between healthy individuals, patients with chronic renal failure, and immunocompromised populations. Transplant Proc 2014;46:328-31. 7. Basu I, Agarwal M, Shah V, et al. Immunogenicity and safety of two quadrivalent influenza vaccines in healthy adult and elderly participants in India - A phase III, active-controlled, randomized clinical study. Hum Vaccin Immunother. 2022 Dec 31;18(1):1-10. 8. Kroon FP, van Dissel JT, de Jong JC, van Furth R. Antibody response to influenza, tetanus and pneumococcal vaccines in HIV-seropositive individuals in relation to the number of CD4+ lymphocytes. AIDS 1994;8:469-76. Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Downloaded from http://journals.lww.com/jaids by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A 15 WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/07/2023 9. Yamanaka H, Teruya K, Tanaka M, Kikuchi Y, Takahashi T, Kimura S, Oka S; HIV/Influenza Vaccine Study Team. Efficacy and immunologic responses to influenza vaccine in HIV-1- infected patients. J Acquir Immune Defic Syndr 2005;39:167-73. 10. Malaspina A, Moir S, Orsega SM, Vasquez J, Miller NJ, Donoghue ET, Kottilil S, Gezmu M, Follmann D, Vodeiko GM, Levandowski RA, Mican JM, Fauci AS. Compromised B cell responses to influenza vaccination in HIV-infected individuals. J Infect Dis 2005;191:1442-50. 11. Parmigiani A, Alcaide ML, Freguja R, Pallikkuth S, Frasca D, Fischl MA, Pahwa S. Impaired antibody response to influenza vaccine in HIV-infected and uninfected aging women is associated with immune activation and inflammation. PLoS One 2013;8:e79816. 12. George VK, Pallikkuth S, Parmigiani A, Alcaide M, Fischl M, Arheart KL, Pahwa S. HIV infection worsens age-associated defects in antibody responses to influenza vaccine. J Infect Dis 2015 ;211:1959-68. 13. McKittrick N, Frank I, Jacobson JM, White CJ, Kim D, Kappes R, DiGiorgio C, Kenney T, Boyer J, Tebas P. Improved immunogenicity with high-dose seasonal influenza vaccine in HIV- infected persons: a single-center, parallel, randomized trial. Ann Intern Med 2013;158:19-26. 14. Fourati S,et al. Pan-vaccine analysis reveals innate immune endotypes predictive of antibody responses to vaccination. Nat Immunol. 2022 Dec;23(12):1777-1787. 15. Royston L, et al. Cytomegalovirus as an Uninvited Guest in the Response to Vaccines in People Living with HIV. Viruses. 2021 Jun 29;13(7):1266. 16. Speer C, Schaier M, Nusshag C, Töllner M, Buylaert M, Kälble F, et al. Longitudinal humoral responses after COVID-19 vaccination in peritoneal and hemodialysis patients over twelve weeks. Vaccines (Basel) 2021;9:1130. Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Downloaded from http://journals.lww.com/jaids by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A 16 WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/07/2023 17. Salk JE. A simplified procedure for titrating hemagglutinating capacity of influenza virus and the corresponding antibody. J Immunol 1944;49:87–98. Abbreviations: BMI, body mass index; WBC, white blood cell count; ALC, absolute lymphocyte count; NNRTI, non-nucleoside reverse transcriptase inhibitor; COVID-19, corona virus disease 2019 variant; IIV4, quadrivalent influenza vaccine; SD, standard deviation; IQR, interquartile range Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

17 Downloaded from http://journals.lww.com/jaids by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A Figure 1 Study flow chart WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/07/2023 Figure 1 Study flow chart Abbreviations: HIV, human immunodeficiency virus Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Downloaded from http://journals.lww.com/jaids by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A 18 WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/07/2023 Figure 2. Geometric mean titer ratio of post and pre-vaccination with quadrivalent inactivated influenza vaccine Figure 2. Geometric mean titer ratio of post and pre-vaccination with quadrivalent inactivated influenza vaccine Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Downloaded from http://journals.lww.com/jaids by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A 19 WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/07/2023 Figure 3 Seroprotection (A) and seroconversion (B) rate with quadrivalent inactivated influenza vaccination Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Downloaded from http://journals.lww.com/jaids by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A 20 WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/07/2023 Figure 3 Seroprotection (A) and seroconversion (B) rate with quadrivalent inactivated influenza vaccination Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

21 Table 1 Demographic data of 70 persons with HIV Downloaded from http://journals.lww.com/jaids by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A Characteristics Total CD4 cell CD4 cell counts P-value WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/07/2023 (n=70) counts >350 cells/mm3 0.310 0.490 ≤350 cells/mm3 (n=59) 0.840 0.048 (n=11) 0.013 Male, n (%) 45 (64) 9 (82) 36 (61) <0.001 Age, years, mean (SD) 46.1 (8.7) 47.8 (8.7) 45.8 (8.8) BMI, kg/m2, mean (SD) 23.3 (3.9) 23.1 (3.0) 23.4 (4.1) 0.730 WBC, cells/mm3, mean 6396 (1516) 6551.9 (1514.6) 0.620 5561.8 0.680 0.750 (SD) 2320 (723) (1367.5) 1.000 ALC, cells/mm3, mean 1826.5 (666.2) 2412.5 (700.9) 1.000 (SD) 0.210 CD4 cell counts, 601.5 (265) 264.5 (56.2) 664.3 (239.5) cells/mm3, mean (SD) Comorbidities, n (%) None 22 (31) 4 (36) 18 (31) Hypertension 9 (13) 2 (18) 7 (12) Diabetes mellitus 13 (19) 1 (9) 12 (20) Dyslipidemia 30 (43) 4 (36) 26 (44) Chronic kidney 5 (7) 1 (9) 4 (7) disease Others 12 (17) 2 (18) 10 (17) Antiretroviral regimen, n Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

22 (%) Downloaded from http://journals.lww.com/jaids by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A NNRTI-based 52 (74) 6 (55) 46 (78) WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/07/2023 Integrase inhibitor- 12 (17) 3 (27) 9 (15) based Protease inhibitor- 6 (9) 2 (18) 4 (7) based History of influenza 0.500 vaccination, n (%) None 24 (34) 5 (45) 19 (32) ≤2 years 30 (43) 3 (27) 27(46) >2 years 16 (23) 3 (27) 13 (22) Duration between 54.4 (30) 44.8 (28.7) 55.9 (29.8) 0.291 COVID-19 vaccines and IIV4, days mean (SD) Abbreviations: BMI, body mass index; WBC, white blood cell count; ALC, absolute lymphocyte count; NNRTI, non-nucleoside reverse transcriptase inhibitor; COVID-19, coronavirus disease 2019 variant; IIV4, quadrivalent influenza vaccine; SD, standard deviation Table 2 Geometric mean titer, seroprotection and seroconvertion at post-vaccination for each strain in the quadrivalent influenza vaccine Strain CD4 cell CD4 cell P-Value RR P-Value Adjusted* P-Value RR counts counts (95%CI) ≤350 >350 Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

23 cells/mm cells/mm3 (95%CI) 3 (n=59) Downloaded from http://journals.lww.com/jaids by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/07/2023 (n=11) A/Victoria/2570/2019 (H1N1)pdm09-like virus Geometric mean 1333 881 0.231 titer (2012) (828) Seroprotection 9 50 1.04 1.000 0.81 0.685 Day 28, n (%) (81.8) (84.8) (0.77- (0.29- 0.485 1.40) 2.33) 0.65 Seroconversion, 7 39 1.04 1.000 (0.20- n (%) (63.4) (66.1) (0.54- 2.17) 1.68) Geometric mean 1210 A/Hong Kong/2571/2019-like virus (H3N2) titer (1812) 552 0.076 (855) Seroprotection 8 58 1.35 0.011 1.38 0.516 Day 28, n (%) (72.3) (98.3) (1.13- 0.106 (0.52- 0.285 1.61) 3.67) 2.24 Seroconversion, 3 33 2.05 (0.51- n (%) (27.3) (55.9) (0.76- 9.82) 5.53) B/Phuket/287/2013 Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Geometric mean 164 222 24 titer (192) (218) 0.417 Downloaded from http://journals.lww.com/jaids by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A Seroprotection 8 58 1.35 0.011 1.23 0.676 WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/07/2023 Day 28, n (%) (72.3) (98.3) (1.13- (0.46- 0.944 1.61) 3.29) 0.95 Seroconversion, 4 34 1.58 0.323 (0.24- n (%) (36.4) (57.6) (0.70- 3.82) 3.57) B/Washington/02/2019 Geometric mean 1902 1285 0.193 titer (1957) (1176) Seroprotection 10 50 0.93 1.000 0.81 0.685 Day 28, n (%) (90.9) (84.8) (0.75- (0.29- 1.15) 2.23) Seroconversion, 8 43 1.00 1.000 0.58 0.355 n (%) (72.3) (72.9) (0.68- (0.18- 1.49) 1.85) Abbreviations: SD, standard deviation; IQR, interquartile range, N/A, not applicable Table 3 Characteristics of persons with HIV with or without seroprotection and seroconversion against A/Victoria/2570/2019 (H1N1)pdm09-like virus strain No Seroprotection p-value No Seroconversi p- Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

25 seroprotectio (n=59) seroconversion on value (n=24) (n=46) 0.800 Downloaded from http://journals.lww.com/jaids by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A n 0.840 WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/07/2023 0.800 (n=11) 0.700 0.490 Male gender, 7 (64) 38 (64) 1.000 16 (67) 29 (63) 0.880 n (%) 1.000 Age, years, 51.8 45.1 (8.8) 0.017 46.4 46.0 (9.9) (8.2) mean (SD) (6.1) 23.6 (4.1) 0.220 23.2 23.4 BMI, kg/m2, 22.0 (3.5) (4.2) 6298.8 6447.2 mean (SD) (2.4) (1574.8) (1516.2) WBC, 6291.8 6415.8 0.810 cells/mm3, (1337.9) (1569.0) mean (SD) ALC, 2357.9 2313.4 0.850 2404.2 2276.7 cells/mm3, (840.9) (707.5) (765.4) (705.3) mean (SD) CD4 cell 613 599.4 0.880 613 599.4 (267.3) (263.8) (267.3) count, (263.8) cells/mm3, mean (SD) CD4 group ≤350 2 (18) 9 (15) 1.000 4 (17) 7 (15) cell/mm3 39 (85) >350 9 (82) 50 (85) 20 (83) Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

26 Downloaded from http://journals.lww.com/jaids by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A cell/mm3 5 (45) 17 (29) 0.300 10 (42) 12 (26) 0.280 WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/07/2023 Comorbidities 1 (9) 8 (14) 1.000 5 (21) 4 (9) 0.260 , n (%) 0 (0) 13 (22) 0.110 2 (8) 0.190 None 4 (36) 11 (24) Hypertension 1 (9) Diabetes 26 (44) 0.750 9 (38) 21 (46) 0.610 mellitus 0 (0) 4 (7) 1.000 3 (13) 2 (4) 0.330 Dyslipidemia Chronic 8 (73) 12 (20) 0.190 3 (13) 9 (20) 0.530 kidney 1 (9) disease 44 (75) 1.000 15 (63) 37 (80) 0.150 Others 2 (18) 11 (19) 0.680 4 (17) 8 (17) 1.000 Antiretroviral regimen, n 4 (7) 0.240 5 (21) 1 (2) 0.016 (%) NNRTI-based Integrase inhibitor- based Protease inhibitor- based History of Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

27 Downloaded from http://journals.lww.com/jaids by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A influenza 6 (55) 18 (31) 0.250 9 (38) 15 (33) 0.330 WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/07/2023 vaccination, n 4 (36) 26 (44) 0.096 12 (50) 18 (39) 0.770 (%) 1 (9) 15 (25) 3 (13) 13 (28) None 38.1 57.2 (30.7) ≤2 years (20.0) 52.8 55.3 >2 years (34.9) (27.6) Duration between COVID-19 vaccines and IIV4, days Mean (SD) Abbreviations: BMI, body mass index; WBC, white blood cell count; ALC, absolute lymphocyte count; NNRTI, non-nucleoside reverse transcriptase inhibitor; COVID-19, corona virus disease 2019 variant; IIV4, quadrivalent influenza vaccine; SD, standard deviation; IQR, interquartile range Table 4 Characteristics of persons with HIV with or without seroprotection and seroconversion against A/Hong Kong/2571/2019-like virus (H3N2) strain No Seropro p-value No Serocon p-value seroprotection tection seroconver version Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

28 Downloaded from http://journals.lww.com/jaids by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A Male gender, N=4 N=66 0.610 sion N=34 N=36 0.620 WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/07/2023 n (%) 2 (50) 43 (65) 23 (68) 22 (61) Age, years, mean (SD) 49.8 45.9 0.400 44.1 48 0.063 BMI, kg/m2, (8.7) (8.8) 0.980 (10.0) (7.0) 0.600 mean (SD) 23.3 23.3 0.880 23.1 23.6 0.210 WBC, (4.3) (3.9) (3.0) (4.7) cells/mm3, 6287.5 6402.9 6161.2 6618.3 mean (SD) (1070.9) (1555.8) (1687.6) (1343.8) ALC, cells/mm3, 2456.8 2312.2 0.700 2238.2 2398.1 0.360 mean (SD) (578.4) (734.2) (725.5) (723.1) CD4 cell count, 522.8 606.3 0.540 576.8 624.8 0.450 cells/mm3, (562.1) (244.0) (279.3) (252.2) mean (SD) CD4 group 3 (75) 8 (12) 0.011 8 (24) 3 (8) 0.110 ≤350 cell/mm3 1 (25) 58 (88) 26 (76) 33 (92) >350 cell/mm3 Comorbiditie Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

29 Downloaded from http://journals.lww.com/jaids by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A s, n (%) 1 (25) 21 (32) 1.000 14 (41) 8 (22) 0.120 WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/07/2023 None 1 (25) 8 (12) 0.430 3 (9) 6 (17) 0.480 Hypertensio 0 (0) n 2 (50) 13 (20) 1.000 3 (9) 10 (28) 0.064 Diabetes 1 (25) mellitus 28 (42) 1.000 13 (38) 17 (47) 0.480 Dyslipidemia 0 (0) 4 (6) 0.260 3 (9) 2 (6) 0.670 Chronic kidney 3 (75) 12 (18) 1.000 5 (15) 7 (19) 0.750 disease 1 (25) Others 49 (74) 1.000 24 (71) 28 (78) 0.590 Antiretroviral 0 (0) regimen, n 11 (17) 0.540 7 (21) 5 (14) 0.540 (%) NNRTI- 6 (9) 1.000 3 (9%) 3 (8) 1.000 based Integrase inhibitor- based Protease inhibitor- based History of Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

30 Downloaded from http://journals.lww.com/jaids by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A influenza 3 (75) 21 (32) 0.270 8 (24) 16 (44) 0.190 WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/07/2023 vaccination, 1 (25) 29 (44) 0.840 17 (50) 13 (36) 0.015 n (%) 0 (0) 16 (24) 9 (26) 7 (19) None ≤2 years 51 54.7 65.1 45.6 >2 years (13.2) (30.8) (30.2) (27.3) Duration between COVID-19 vaccines and IIV4, days Mean (SD) Abbreviations: BMI, body mass index; WBC, white blood cell count; ALC, absolute lymphocyte count; NNRTI, non-nucleoside reverse transcriptase inhibitor; COVID-19, corona virus disease 2019 variant; IIV4, quadrivalent influenza vaccine; SD, standard deviation; IQR, interquartile range Table 5 Characteristics of persons with HIV with or without seroprotection and seroconversion against B/Phuket/287/2013 strain No Seropro P value No Serocon P value seroprotection tection seroconver version Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

31 N=4 N=66 sion N=32 N=38 43(65) Downloaded from http://journals.lww.com/jaids by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A Male gender, 2(50) 0.610 24(75) 21(55) 0.130 WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/07/2023 n (%) Age, years, 49.5 45.9(8.9) 0.430 45.0 47.1 0.320 0.450 (9.1) (8.4) 0.500 mean (SD) (4.8) 23.2(4.0) 1.000 23.7 23.0 0.120 BMI, kg/m2, 24.8 (2.8) (4.7) 6396.4 6084.7 6658.7 mean (SD) (3.2) (1546.8) (1458.1) (1552.7) WBC, 6395 cells/mm3, (1330.1) mean (SD) ALC, 2184.5 2328.7 0.700 2289.8 2346.3 0.750 cells/mm3, (687.2) (729.8) (752.2) (707.5) mean (SD) CD4 cell 302.5 619.6 0.019 578.3 621.1 0.500 (261.5) (275.6) (257.7) count, (79.0) cells/mm3, mean (SD) CD4 group ≤350 3(75) 8(12) 0.011 7(22) 4(11) 0.320 cell/mm3 >350 1(25) 58(88) 25(78) 34(89) cell/mm3 Comorbiditie Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

32 s, n (%) Downloaded from http://journals.lww.com/jaids by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A None 1(25) 21(32) 1.000 11(34) 11(29) 0.800 WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/07/2023 8(12) 0.430 5(16) 4(11) 0.720 Hypertensio 1(25) n Diabetes 0(0) 13(20) 1.000 3(9) 10(26) 0.120 mellitus Dyslipidemia 3(75) 27(41) 0.310 12(38) 18(47) 0.470 5(8) 1.000 3(9) 2(5) 0.650 Chronic 0(0) kidney disease Others 0(0) 12(18) 1.000 8(25) 4(11) 0.130 Antiretroviral regimen, n (%) NNRTI- 3(75) 49(74) 3 21(66) 31(82) 0.170 11(17) (75%) 7(22) 5(13) 0.360 based 1 (25%) Integrase 1(25) inhibitor- based Protease 0(0) 6(9) 0(0%) 4(13) 2(5) 0.400 inhibitor- based History of Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

33 influenza Downloaded from http://journals.lww.com/jaids by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A vaccination, WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/07/2023 n (%) None 2(50) 22(33) 0.670 8 (25) 16 (42) 0.220 28(42) 0.420 ≤2 years 2(50) 16(24) 17 (53) 13 (34) 55.3(30.6) >2 years 0(0) 7 (22) 9 (24) Duration 40.7 58.6 (34.1) 51.0 (26.2) 0.360 between (15.0) COVID-19 vaccines and QIV, days Median (IQR) Abbreviations: BMI, body mass index; WBC, white blood cell count; ALC, absolute lymphocyte count; NNRTI, non-nucleoside reverse transcriptase inhibitor; COVID-19, corona virus disease 2019 variant; IIV4, quadrivalent influenza vaccine; SD, standard deviation; IQR, interquartile range Table 6 Characteristics of persons with HIV with or without seroprotection and seroconversion against B/Washington/2019 strain No Seropro p-value No Serocon p-value seroprotect tection seroconver version Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

34 ion N=60 sion N=19 N=51 N=10 Downloaded from http://journals.lww.com/jaids by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A Male gender 6(60) 39 (65) 0.740 12(63) 33 (65) 1.000 WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/07/2023 Age, years, 51.6 45.2 0.031 49.6 44.8 0.042 mean (SD) (6.3) (8.8) (7.1) (9.0) BMI, kg/m2, 22.1 0.290 23.6 23.2 0.720 mean (SD) (2.5) 23.5(4.1) (3.3) (4.2) WBC, 6335 0.890 6551.1 0.610 cells/mm3, (1402.2) 6406.5 (1423.5) 6338.6 mean (SD) (1557.3) (1573.1) ALC, 2353.4 cells/mm3, (886.2) 2314.9 0.880 2503.4 2252.3 0.200 mean (SD) (701.5) (794.5) (691.1) CD4 cell 648.9 count, (248.1) 593.6 0.540 584.2 607.9 0.740 cells/mm3, (268.8) (231.5) (278.2) mean (SD) 1(10) CD4 group 10(17) 1.000 3(16) 8(16) 1.000 ≤350 9(90) cell/mm3 50(83) 16(84) 43(84) >350 cell/mm3 Comorbiditie Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

35 Downloaded from http://journals.lww.com/jaids by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A s 5(50) 17(28) 0.270 7(37) 15(29) 0.570 WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/07/2023 None 1(10) 8(13) 1.000 5(26) 4(8) 0.054 Hypertensio 0(0) n 3(30) 13(22) 0.190 2(11) 11(22) 0.490 Diabetes 1(10) mellitus 27(45) 0.500 9(47) 21(41) 0.790 Dyslipidemia 0(0) 4(7) 0.550 2(11) 3(6) 0.610 Chronic kidney 7(70) 12(20) 0.190 1(5%) 11(22) 0.160 disease 1(10) Others 45(75) 0.710 11(58) 41(80) 0.070 Antiretroviral 2(20) regimen 11(18) 1.000 4(21) 8(16) 0.720 NNRTI- based 4(7) 0.200 4(21) 2(4) 0.042 Integrase inhibitor- based Protease inhibitor- based History of influenza Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

36 vaccination Downloaded from http://journals.lww.com/jaids by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A None 6(60) 18(30) 0.250 8(42) 16(31) 0.340 WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/07/2023 ≤2 years 3(30) 27(45) 9(47) 21(41) >2 years 1(10) 15(25) 2(11) 14(27) Duration 38.1 57.2(30.7) 0.096 46.8 57.6 0.230 between (20.1) (27.6) (30.7) COVID-19 vaccines and QIV, days Mean (SD) Abbreviations: BMI, body mass index; WBC, white blood cell count; ALC, absolute lymphocyte count; NNRTI, non-nucleoside reverse transcriptase inhibitor; COVID-19, corona virus disease 2019 variant; IIV4, quadrivalent influenza vaccine; SD, standard deviation; IQR, interquartile range Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.