PrEP and Prevention for the Older Person (Updated 1/13/18)

  • Older adults should be strongly considered as appropriate candidates for PrEP.
  • Older adults should be strongly considered as appropriate candidates for PrEP if they fall into risk categories.
  • The provider may be able to target PrEP use by the sexual partners of PLWH, especially for discordant couples.

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) Significant research data shows that antiretroviral therapy (ART), while sustaining the health of PLWH, also results in the prevention of HIV infections. When the HIV-positive person is virally suppressed, analyses of thousands of couples and acts of condomless sex, HIV transmissions to an HIV-negative partner do not occur. ART results in viral suppression, defined as less than 200 copies/ml. Obtaining  viral suppression (or an undetectable viral load) on ART,  prevents sexual HIV transmission [1]. The CDC formally embraced this science in September 2017, and many other researchers and organizations have now embraced the Prevention Access Campaign’s U=U (HIV Undetectable = Untransmittable) [http://www.thelancet.com/pdfs/journals/lanhiv/PIIS2352-3018(17)30183-2.pdf].
  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 contact point 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, have the opportunity to increase the uptake of PrEP in what are perceived as hard-to-reach at-risk groups.   Unfortunately, no studies have focused specifically on PrEP use in older adults, although some clinical cohorts in San Francisco, included patients in their late 60s [18].

Without more data, it is difficult to know if older adults may be at increased risk of toxicity from PrEP, which is a concern raised by many providers as older adults are already at increased risk for osteoporosis and decreased age associated renal clearance.  Some data has suggested adults over age 50 may be at increased risk of renal toxicity [https://www.projectinform.org/news/croi-2016-serious-kidney-problems-are-rare-with-prep-but-increase-with-older-age-and-better-adherence].  The CDC guidelines do not recommend PrEP for patients with chronic kidney disease (CrCl <60). For now, providers should follow current guidelines for monitoring toxicity.  The CDC does not recommend routine DEXA screens before initiating PrEP (CDC Guidelines 2014).

Reasons to support PrEP use in older adults:

  • 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].
  • 15 to 20% of older adults living 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 cannot become pregnant. 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. In addition, given this information, primary care providers need to engage in sexual history taking with older adults and determine risk. 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 older 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.

Ending the AIDS Epidemic

A detailed comprehensive report developed as part of the NEW YORK STATE ENDING THE EPIDEMIC effort, Older Adults (50+) and HIV Advisory Group Report Older Adult Implementation Strategies (OAIS) [16] addresses PrEP in the context of older adults living with HIV.  The report details reasons for offering PrEP to older adults:

  1. Half of men aged 40 years and older have erectile dysfunction, making condom use problematic to protect against HIV.
  1. Research finds few older men or women use condoms.
  2. Providers are not routinely discussing sexual health with older patients leaving at-risk patients undiscovered.
  1. Older women encounter challenges negotiating condom use with partners. The insistence of condom use is often perceived as implying the partner is gay, IDU, or HIV+). This may create situations of domestic/elder abuse.  PrEP allows older women to be empowered about their sexual health.
  1. HIV testing rates among adults over 50 are very low. Encouraging PrEP can increase HIV testing rates in this group.

The report [16] details implementation strategies whereby one can connect high-risk negative older adults to HIV prevention efforts including PrEP.  These include targeted messaging and promoting education of medical and non-medical providers on the application of PrEP. Targeting must consider those locations where older adults assemble or derive day to day information. These may be conventional sources like newspapers, radio, TV, etc.) or social media as well as senior centers, CBOs providing social services, or age specific communities. Further, it is essential that images of older adults are represented in social messaging campaigns [17].

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.

Updated by Stephen Karpiak, Ph.D.

October 2017.

References

  1. CDC. US Public Health Service PrEP for the Prevention of HIV Infection in the US – A Clinical Practice 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 Assis 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
  16. Advisory Group. NEW YORK STATE ENDING THE EPIDEMIC Older Adults (50+) and HIV Advisory Group Report: Older Adult Implementation Strategies (OAIS) https://www.health.ny.gov/diseases/aids/ending_the_epidemic/docs/older_adults_advisory_group.pdf
  17. Karpiak S, Lunievicz J. Age is Not a Condom: HIV and Sexual Health for Older Adults Current Sexual Health 2017 (Springer Science)
  18. Volk JE, Marcus JL, Phengrasamy T, Blechinger D, Nguyen DP, Follansbee S, Hare CB. No New HIV Infections With Increasing Use of HIV Preexposure Prophylaxis in a Clinical Practice Setting. Clin Infect Dis. 2015 Nov 15;61(10):1601-3.
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