Hepatitis B virus (HBV) coinfection accelerates immunologic progression in patients with primary HIV infection in an area of hyperendemicity for HBV infection.

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To the Editor-We are pleased to respond to the comments by Ruiz-Alejo et al [1], regarding the need to conduct future studies of the live attenuated tetra-valent dengue vaccine in areas endemic for dengue. We could not agree more that candidate dengue vaccines will need to be studied in the populations identified as targeted for eventual vaccination. Our study was a phase I clinical trial and was thus focused primarily on safety. Because preexisting immunity to >1 fia-vivirus can affect the antibody response to vaccination with live attenuated dengue vaccine candidates [2-4], we thought it would be most appropriate to conduct the first evaluation of this promising candidate vaccine in flavivirus-naive adults. We have 2 phase 2 trials planned for dengue-endemic areas (Brazil and Thailand), and these trials will enroll fiavivi-rus-experienced individuals. Enrollment in dengue-endemic areas will proceed in an age deescalated manner to ensure that the safety profile of the vaccine is acceptable in adults and older children before enrolling younger children.