- Providers must reduce barriers to effective prevention and detection of HIV in older
- Primary care providers should perform routine, opt-out HIV screening in all adults, regardless of age or individual factors, with repeat HIV screening at least annually in patients at known
We recommend routine, opt-out screening for HIV infection in all adults, including those over the age of 65. As described below, HIV screening based on identification of risk factors alone is not effective, especially since older adults may be more likely than the general population to have unrecognized risks, and are therefore more likely to present late in the course of infection with HIV/AIDS. Since early initiation of antiretroviral therapy is critical to successful treatment, and routine screening is more effective than risk-based screening in identifying HIV earlier in older adults, we recommend that all adults regardless of age should be screened for HIV.
The number of older adults with HIV/AIDS is increasing, partly because people with HIV/AIDS are living longer. According to the Center for Disease Control and Prevention (CDC), from 2010 to 2013, the number of adults over the age of 50 living with HIV increased from 301,970 to 395,668 with individuals ages 50-54 years old making up the majority (41%) of HIV positive older adults (CDC, 2016a). By the end of 2014, adults over the age of 50 represented approximately 46% (437,671) of all individuals living with HIV in the US (CDC, 2016c). Additionally, there has been a continued lack of attention to the rate of new infections in older adults. In 2014, 17% of the 44,073 newly diagnosed HIV infections in the US were in those 50 years and older, and 44% of those were between the ages of 50 and 54 (CDC, 2016b). While the prognosis for newly diagnosed HIV positive individuals has improved amongst most age groups, this has not necessarily been the case for older adults. In 2013, a disproportionate percentage of older adults (37.7% ) were diagnosed with stage 3 AIDS at time of HIV diagnosis (CDC, 2016a).
Detecting HIV in older adults is not only important because of the increased prevalence amongst older adults, but also because older adults are more likely to present late, with greater associated mortality (Chadborn et al. 2006). A UK study found that 48% of older adults were late presenters vs. 33% of younger adults (Smith et al. 2010 and Althoff et al., 2010). Older adults in this study were 14 times more likely to die within a year of diagnosis compared with older adults who were not diagnosed late. Another UK study of 63,805 adults diagnosed with HIV, showed that older adults derived greater absolute risk reduction and mortality benefits with early initiation of ART therapy than their younger counterparts making early detection and treatment essential (Davis et al., 2013). One of the main reasons for late diagnosis is the lack of awareness by both patients and providers.
Screening for HIV/AIDS requires awareness of risk factors, which may be different in older adults. In contrast to younger adults, the main risk factor in older adults is heterosexual intercourse, though the route of HIV infection is often unknown (Grabar et al. 2006; Martin et al. 2008; Sherr et al. 2009). There are however differences based on gender, with 67% of men over 50 years old contracting HIV by male-male sexual contact, 20% heterosexual contact, and 10% injection drug use, as compared to women with 85% by heterosexual contact and 15% by injection drug use (CDC, 2016a). Older women may be at increased risk of HIV due to age-related vaginal thinning and dryness, and also because older women starting a new sexual relationship after many years of being in a monogamous relationship may find it difficult to initiate discussions about risks and the use of condoms (CDC, 2016b). Older women may also find it difficult to self-advocate for condom use due to sexism and power differentials within their relationships (Altschuler & Rhee, 2015). Additionally, increasing prevalence of erectile dysfunction as men age may make condom use less desirable and even more challenging, while the availability of medication to treat erectile dysfunction may also allow for increased sexual activity in older men (Jones, Fenkl, Patsdaughter, & Chadwell, 2013).
Minority races/ethnicities may also have increased risk factors (Zingmond et al. 2001, Linley 2012). Blacks/African Americans continue to be the most disproportionately affected race/ethnicity with rates of new HIV infections being 2 times that of Hispanics/Latinos and 8 times that of whites (CDC, 2016a). Older adults who are lesbian, gay, bisexual or transgender (LGBT) are an additional group at increased risk, especially men who have sex with men, who account for just over half of all new HIV infections (CDC, 2016a). Older LGBT adults are often invisible to the health care profession for multiple reasons, which can further impair effective communication and reduction of risk (Grossman 1995; Simone & Appelbaum, 2011).
Barriers to effective prevention and detection include:
- Lack of knowledge about HIV/AIDS by older adults/reluctance to discuss sexuality: Older women have poor knowledge about HIV risk factors (Henderson et al. 2004). Older adults are also often ignored or forgotten in typical prevention campaigns that generally target youth (Pratt et al. 2010). Older patients also report receiving little information about sexual health, HIV, and other sexually transmitted infections (STIs) from their physicians, despite still being sexually active (Lindau et al. 2007; Stall & Catania 1994). Many older people do not consider themselves at risk for contracting HIV and therefore do not get tested (Dalrymple et al., 2016). A 2009 survey of over 12,000 older adults found that only 25% had ever been tested, and of those tested, 70% had been more than 5 years ago (Adekeye et al. 2012). Respondents identified very low perceived risk of HIV infection (98% reported risk as low or none), and lower perception of risk was associated with decreased likelihood of being tested. Lower perceived risk likely contributes to lower rates of condom use amongst older adults as compared to younger adults. For instance, only 20% of men and 24% of women reported condom use during their last sexual encounter, and yet the majority of men (64.4%) and women (68.9%) reported that they had not received an STI test within the past year (Schick et al. 2010). A systematic review of HIV prevention programs that target older adults suggests three models of education: group education programs delivered by social workers or other health professionals, peer education models, and one-on-one early intervention models including HIV/AIDS testing (Milaszewski et al. 2013). Increasing attention has been paid to the critical need for more effective prevention programs for older adults, as was discussed at a White House summit on HIV and aging in 2010. Various resources and campaigns now exist (Brooks et al., 2012).
- Underestimation of risk by healthcare providers/ageism: Healthcare providers may not consider discussing HIV/AIDS with older patients, and may also lack the correct knowledge about risk factors in older patients (Skiest & Keiser 1997). They may incorrectly assume that older patients are not sexually active or do not use drugs, or may be uncomfortable raising these issues with older patients (Brooks et al., 2012; CDC, 2016 June). Providers are also much less likely to document the sexual history of older adults (Loeb et al. 2011). However, older adults remain sexually active: 53% of those 65-75 years old, and 26% of those 75-85 years old, report sexual activity (Lindau et 2007). In addition, older adults with HIV also remain sexually active (27%), with only 68% reporting consistent condom use (Onen et al. 2010). A national survey of providers found that they had difficulty ranking the four most common risk factors for HIV infection in older adults, and only 6% were able to correctly rank all four (Hughes 2012).
- Misdiagnosis/delay: Making the diagnosis of HIV/AIDS in older adults can be challenging because the symptoms can mimic normal aging or other medical conditions common in the elderly, such as fatigue, weight loss, mental confusion, and frailty (Lekas et 2005). A retrospective analysis of HIV positive women found missed opportunities for diagnosis in their older cohort (>44 years old), who were also more likely to be late-testers (diagnosed with AIDS <12 months of diagnosis of HIV), and they were more likely to have no identifiable risk factor for HIV transmission (Duffus et al. 2012).
- Stigma: Older adults with HIV may be more likely to experience greater stigma from their peers due to the association of HIV with homosexuality and substance abuse, leading them to hide their diagnosis or risk factors from providers or family (CDC, 2016b June). Unfortunately, older patients have little interest in HIV testing, even in the presence of risk factors (Akers et al, 2007; Lekas et 2005; Mack & Bland, 1999).
Providers must work to address the barriers to effective screening and discussions regarding HIV prevention. Communication between health care providers and their older patients in regards to topics such as safer sex methods is critical. Providers must use medical histories that include questions regarding older adults’ sexual behavior, sexual orientation, and substance use. Additionally, provider endorsement of HIV testing should not be underestimated as it is associated with higher rates of screening (Craig et al. 2012). Removing unnecessary barriers to testing, such as the need for written consent, also improves screening rates (Nayak et al. 2012). Providers should not only have a lower threshold to screen for and consider the diagnosis of HIV in older patients, but they must also engage patients of all ages in discussions about sexual health and risk prevention. (see Sexual Health section).
The CDC recommends voluntary, routine opt-out HIV screening for all adults age 13-64, regardless of risk factors (Branson et al. 2006). Those with known risk factors should have repeat HIV screening at least annually. These guidelines discourage screening based solely on risk factors, because targeted testing in the general population on the basis of risk behaviors alone fails to identify a substantial number of persons who are HIV infected (Branson et al. 2006). In 2013, the U.S. Preventive Services Task Force updated their screening recommendations, and similar to the CDC, recommend routine screening for all adolescents and adults age 15-65 (grade A recommendation) (Moyer et al. 2013). These recommendations unfortunately provide a cut-off at 65 years old, at which point routine screening is no longer recommended, despite the fact that older adults and providers are unable to correctly identify risk factors for HIV infection (Henderson et al. 2004; Skiest & Keiser, 1997). Analyses of HIV screening in older adults show that one-time routine screening of adults up to the age of 75 may also be cost-effective (Sanders et al. 2005).
Given that the cost and risk of physical harm from an HIV test is much less than other established screening tests (e.g. colonoscopy), and since the potential benefits of earlier detection are great, we recommend routine screening of all older adults. Routine screening is more effective than risk-based screening, perhaps even more so in older adults, where providers and patients are less likely to identify risks for HIV infection. In addition to the public health benefit of reduction in HIV transmission in older patients, routine screening may also improve individual outcomes as a result of earlier treatment (the treatment of HIV/AIDS in older adults is discussed separately in this document). Unlike most screening recommendations in the elderly which should account for the individual’s functional status, comorbidities, and predicted life expectancy, we recommend routine testing of all older patients, regardless of age or individual factors, since effective and acceptable treatment options exist, and routine detection would reduce further transmission of HIV in the older population.
Updated by Nathan Wass, M.D.
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