A long-term HIV survivor, 66-year-old Frank Pizzoli is fastidious about his health, especially during flu season. He gets vaccinated every fall and has even developed a small ritual of hand sanitizer, saline, and mouthwash every time he comes home during the winter -- extra insurance against the flu, he figures.
But this year, Pizzoli's typical anti-flu ritual wasn't enough. On Dec. 23, he started feeling fatigued -- the early signs of an influenza infection that would leave him coughing and feverish for the next two-and-a-half weeks.
Pizzoli isn't alone. This season's flu is considered "moderately severe" and is already "widespread" in 49 states, according to the Centers for Disease Control and Prevention (CDC). Making matters worse, the strain of flu circulating this year -- H3N2 -- is considered one of the deadlier, especially for people over 65.
Although there's no evidence that that this year's flu is hitting older people with HIV harder than others, there's ample reason for older people with HIV to be cautious.
"Influenza is a virus that infects the respiratory tract [but also] evokes a systemic inflammatory response," says William Schaffner, M.D., infectious diseases specialist at the Vanderbilt University Medical Center. "That inflammatory response involves the whole body," he says.
Related: Should I Get a Flu Shot? Flu Vaccine Advice for People Living With HIV
Risk Remains After the Flu Runs Its Course
According to Schaffner, a growing body of research shows that even after the flu has run its course, some risks remain. The "systemic inflammatory response" created by the flu virus increases the risk that blood vessels will develop clots and close off, possibly leading to heart attack and stroke, Schaffner explains.
"Heart attacks and strokes are increased in people who have had influenza, and that increased risk can last a couple of weeks up to a month" after symptoms abate, says Schaffner. "Avoiding influenza might indeed prevent some of those vascular events down the road."
People with HIV are already at higher risk of cardiac events, as well as an overall high risk of influenza-related complications. Meanwhile, the CDC estimates that 71-85% of people who die from the flu every year are 65 and older.
The 2017-2018 flu season has been peppered with controversy, starting in late summer with tabloid stories about a deadly strain of flu hitting Australia during its winter season, which is from June to August. Stoking fears about the "Killer Aussie Flu" were reports that this year's stock of flu vaccine was only 10% effective against the H3N2 strain.
A few months later in the United Kingdom, a systems-wide computer glitch temporarily instructed doctors to halt antiretroviral therapy in HIV patients who had just received the flu shot. The confusion prompted an urgent statement from the HIV Pharmacy Association and the British HIV Association, which emphatically stressed that it's safe to give HIV-positive patients on treatment the flu shot.
Don't Panic -- But Know What to Do
While it's too soon to know exactly how many lives will be claimed by flu this year in the U.S., the death toll has already spiked compared with last year in some states. Despite the alarming news, U.S. public health officials are repeating a message of "don't panic."
Experts emphasize that anyone who got the flu last year is likely to be protected this time around and that the number of flu-related deaths is unlikely to exceed that of the 2014-2015 season, the last time we had a "moderately severe" H3N2 virus.
Still Get the Shot
Schaffner also recognized that it can be frustrating when the flu shot doesn't offer full protection against the flu. But he's spent his career urging people to get vaccinated anyway.
"Get vaccinated every September," he says, "and get anyone in your family, anyone who is close to you vaccinated [to] surround yourself with a cocoon of vaccinated people."
"We have to remember that influenza vaccine is a good, but not perfect, vaccine," says Schaffner. "It's the best science can do for us right now. With our pretty good vaccine, we can do a lot of good."
In addition, while the vaccine's effectiveness was reported at around 10% in Australia, experts expect that the same shot will be about 30% effective in the U.S. One big reason for the difference is that Australia has much more restrictive guidelines on which citizens should be vaccinated, whereas the U.S. recommends vaccination in everyone over six months old, says Schaffner.
"We give much more vaccine, and that changes the whole dynamic of the virus in our communities," says Schaffner. "Last year, when we had the same vaccine and the same virus, essentially, [effectiveness] was 32%."
In addition, the U.S. Food and Drug Administration has approved two flu vaccines specially designed for seniors. One, called Fluzone High-Dose, is basically the same vaccine that everyone gets, but at a higher dose. Approved in 2009, this vaccine works better for seniors by activating a stronger immune response. A second vaccine, called FLUAD, was approved in 2016. It includes an extra ingredient called an "adjuvant" that bolsters the body's immune response, creating a more effective flu shot.
Both of these vaccines are recommended for people over the age of 65 living with HIV. Although Pizzoli, 66 years old, got the FLUAD shot, he still got the flu this season. Still, he suspects his symptoms might have been worse if he never got the shot.
"I've always understood that it's a prophylaxis, but it's not a guarantee," he says. But he recognizes that getting the flu can be frustrating and scary, especially for HIV-positive people who lived during an era when opportunistic infections could be deadly.
Use Flu Antivirals to Treat Flu, or Even to Prevent It, If You've Been Exposed
For those living with HIV who find themselves coming down with the flu, the CDC strongly recommends the use of antiviral medication, such as oseltamivir (also known by the trade name Tamiflu). There are three approved medications; two are oral or inhaled drugs that are usually taken for five days, and the third is given as a 15-30 minute infusion.
For best results, treatment should be initiated within 48 hours of the initial symptoms. The CDC notes:
Treating high risk people or people who are very sick with flu with antiviral drugs is very important. Studies show that prompt treatment with antiviral drugs can prevent serious flu complications. Prompt treatment can mean the difference between having a milder illness versus very serious illness that could result in a hospital stay.
Moreover, it's thought that the treatment can be helpful in shortening the duration of the flu or decreasing severity of symptoms even when initiated after the 48-hour window. And if someone is in close contact with a person who has the flu, the uninfected person can use antivirals prophylactically to avoid getting the flu.
Keep an Eye Out for Other Problems Even After Flu Is Gone -- and Seek Help
If a person -- particularly from a higher-risk group such as older people or those living with HIV -- develops similar or different symptoms a week or two after their flu seems to have resolved, it's important to seek medical attention (including through emergency rooms if needed) as soon as possible to address potentially dangerous secondary infections -- such as pneumonia or sinus -- or consequences of the earlier illness, such as worsening or newly revealed heart problems.
Take Care of Yourself
Pizzoli advises self-care for anyone with HIV who catches the flu this season. "I generally think people my age with HIV -- whether they're as healthy as possible -- tend to blame themselves a lot," he says.
"It's a very easy thing to do, [thinking] 'you must have done something,'" Pizzoli says. But "if there is a time when it would be appropriate and healthy psychologically to make it all about you, it's when you have the flu."