PrEP and the Older Adult with HIV

  • In 2012 the CDC published recommendations for the use of pre-exposure prophylaxis (PrEP) to prevent HIV transmission.
  • Older adults should be strongly considered as appropriate candidates for PrEP if they fall into the risk categories.
  • The care provider may be able to target the sexual partners of their HIV patients jointly.
  • The older adult with HIV, in consultation with the care provider, provides a conduit for the uptake of PrEP by other older adults and other sexual partners.

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To reduce HIV infections in the US, the Centers for Disease Control and Prevention (CDC) is pursuing High-Impact Prevention (HIP) approaches. These methods include combined biological and behavioral interventions that are evidence-based, cost-effective, and often tailored for specific populations and geographic contexts. Key to achieving the greatest impact on the reduction of new HIV infections is the promotion of two highly effective biomedical interventions:

  1. Treatment as Prevention (TasP) for HIV-infected individuals engaged in antiretroviral therapy (ART)
  2. The uptake of pre-exposure prophylaxis (PrEP) among at-risk individuals. Older adults with HIV, in conjunction with their care providers, can serve as an effective conduit for the uptake of PrEP among their HIV-negative partners who are at risk for HIV infection.

The CDC provides clinical guidelines recommending PrEP as an evidence-based intervention to prevent HIV transmission [1]. Multiple clinical trials have demonstrated the efficacy of PrEP [2, 3]. In 2012, the Food and Drug Administration approved tenofovir + emtricitabine (TDF/FTC, Truvada) for use as PrEP in adults [1]. This regimen consists of one pill taken once per day. When taken consistently, it has demonstrated a high level of protection against HIV infection.

How does PrEP fit in the health management of older adults with HIV? Health care providers, with their patients, has the opportunity to increase the uptake of PrEP in what are perceived as hard-to-reach at-risk groups. These are the pertinent supporting facts:

  • In 2015 the CDC reported that 21% of all new HIV infections occur in people age 50 and older [4].
  • Most people engage in sex with peers within their own age group.
  • Condom use declines with age and is used by less than 10% of those over age 50 [5].
  • We know that 15 to 20% of older adults infected with HIV engage in high-risk (unprotected) insertive sex.
  • In multiple studies, older adults with HIV report that their aged peer partners are often not capable of using a condom, due to the inability to sustain an erection [6-9].
  • Many older women with HIV report that they and their male partners do not perceive the need to use a condom because they are post-menopausal. In all cases only condoms can prevent STIs [10,11].

Given this information, older adults with HIV, working with their care providers, can convey to their sexual partners the need to consider the use of PrEP. This significant degree of access should be leveraged by primary care providers, not only as a way to deliver the details of PrEP use, but also as an opportunity for the provider to engage the patient in often avoided discussion about sexual health issues.

A seminal study found that 18% of older adults with HIV were engaging in condomless sex with HIV-negative partners [12]. Although older adults often have sexual relations more with age-matched peers [13], several studies have shown that there is a significant amount of high-risk behavior occurring between younger and older individuals [14,15]. For the older adult with HIV who is having sex with a younger person, the opportunity to encourage the use of PrEP is evident.

Older adults with HIV, with the support of providers, can be effective advocates for the use of PrEP among their seronegative, at-risk sexual partners, be they casual, short-term, or long-term . Many of these at-risk partners are also among those least likely to be routinely tested for HIV. The use of PrEP together with “treatment as prevention” and other prevention interventions (condoms and behavioral interventions) is considered to be an important path toward ending the AIDS epidemic.

Submitted in Feb. 2016 By:  Tonya N. Taylor, Ph.D., M.S., SUNY Downstate Medical Center, and Stephen Karpiak, Ph.D., ACRIA and New York University College of Nursing.

References

  1. CDC. US Public Health Service PrEP for the Prevention of HIV Infection in the US –  A Clinical Ptractice Guideline. 2014.
  2. Treston C, Farley J, Harris O, Hoyt MJ, Kwong J, Van Nuys J. PrEP works and is a valuable addition to the HIV prevention toolkit. J Assoc Nurses AIDS Care 2015,26:224-226.
  3. Caceres CF, O’Reilly KR, Mayer KH, Baggaley R. PrEP implementation: moving from trials to policy and practice. J Int AIDS Soc 2015,18:20222.
  4. CDC. Diagnoses of HIV Infection in the United States and Dependent Areas, 2013. 2015,25.
  5. MacDonald J, Lorimer K, Knussen C, Flowers P. Interventions to increase condom use among middle-aged and older adults: A systematic review of theoretical bases, behaviour change techniques, modes of delivery and treatment fidelity. J Health Psychol 2015.
  6. Guaraldi G, Zona S, Brothers TD, Carli F, Stentarelli C, Dolci G, et al. Aging with HIV vs. HIV seroconversion at older age: a diverse population with distinct comorbidity profiles. PLoS One 2015,10:e0118531.
  7. Glaude-Hosch JA, Smith ML, Heckman TG, Miles TP, Olubajo BA, Ory MG. Sexual Behaviors, Healthcare Interactions, and HIV-Related Perceptions Among Adults Age 60 Years and Older: An Investigation by Race/Ethnicity. Curr HIV Res 2015,13:359-368.
  8. Ford CL, Lee SJ, Wallace SP, Nakazono T, Newman PA, Cunningham WE. HIV testing among clients in high HIV prevalence venues: disparities between older and younger adults. AIDS Care 2015,27:189-197.
  9. Ford CL, Godette DC, Mulatu MS, Gaines TL. Recent HIV Testing Prevalence, Determinants, and Disparities Among US Older Adult Respondents to the Behavioral Risk Factor Surveillance System. Sex Transm Dis 2015,42:405-410.
  10. Pilowsky DJ, Wu LT. Sexual risk behaviors and HIV risk among Americans aged 50 years or older: a review. Subst Abuse Rehabil 2015,6:51-60.
  11. Nevedal A, Sankar A. The Significance of Sexuality and Intimacy in the Lives of Older African Americans With HIV/AIDS. Gerontologist 2015.
  12. Golub SA, Tomassilli JC, Pantalone DW, Brennan M, Karpiak SE, Parsons JT. Prevalence and Correlates of Sexual Behavior and Risk Management Among HIV-Positive Adults Over 50. Sexually Transmitted Diseases 2010:1.
  13. Slater LZ, Moneyham L, Vance DE, Raper JL, Mugavero MJ, Childs G. The multiple stigma experience and quality of life in older gay men with HIV. J Assoc Nurses AIDS Care 2015,26:24-35.
  14. Mustanski B, Newcomb ME. Older sexual partners may contribute to racial disparities in HIV among young men who have sex with men. J Adolesc Health 2013,52:666-667.
  15. Coburn BJ, Blower S. A major HIV risk factor for young men who have sex with men is sex with older partners. J Acquir Immune Defic Syndr 2010,54:113-114.
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