Aroonsiri Sangarlangkarn, MD, MPH, Jonathan S. Appelbaum, MD, FACP

By the end of the session, learners will be able to:

• Describe two risk factors for sexually transmitted diseases (STDs) including HIV in older adults.
   
• Choose three questions that are part of a sexual assessment in older adults. 
   
• Outline two indications and two lab tests required for the initiation of preexposure prophylaxis (PrEP) to prevent HIV transmission.

Reading assignment

• Gornin M. Sexual dysfunction in older adults. Available at: http://www.uptodate.com/contents/sexual-dysfunction-in-older-adults?source=search_result&search=sexual+dysfunction+older&selectedTitle=1~150. Accessed September 4, 2014.
   
• American Academy of HIV Medicine (online). Sexual health in HIV and aging. Available at: http://hiv-age.org/2014/07/16/sexual-health-hiv-aging/. Accessed September 4, 2014.

This case is part of a case-study series on common diseases in aging HIV-infected patients. New cases will be posted monthly on our website. Users should first download the learner portion or read on below, review the suggested reading, and answer the case questions. When you’re ready to check answers, download the answer key to do so. Please contact Ken South at ken@aahivm.org if you’d like more information on the series.

You are free to share, copy, or adapt the series for any purpose, even commercially, as long as you give appropriate credit and indicate if changes were made. Please see our license for more information.

CASE ONE

Mrs. Surprise is a 55-year-old woman with a 48-pack-year smoking history but no significant past medical history who develops progressively worsening dyspnea on exertion over 2 weeks. She received prescription for inhalers and steroid taper from an outpatient clinic last month, but symptoms returned after the steroid taper was completed.

In the emergency room, her temperature is 36.5 °C, pulse 114, respiratory rate 20, oxygen saturation is 94% on 2L. Chest X-ray shows diffuse reticular opacities bilaterally. Her labs are otherwise normal, including white blood cell counts and arterial pH, although her lymphocyte percentage is 8.8. Patient is admitted for pneumonia with COPD exacerbation, treated with antibiotics and steroids.

As part of the workup, Mrs. Surprise undergoes chest CT angiogram to rule out pulmonary embolism, which showed diffuse ground-glass opacities throughout both lungs. Subsequently, diagnostic bronchoscopy is performed, which shows pneumocystis carinii. Rapid HIV testing is positive.

Questions:

1. How common is HIV in patients over 50 years old? How common are new HIV infections?

2. How often do older adults have sex? What about HIV-infected older adults?

3. What factors put older adults at risk of STDs, including HIV?

4. What do you say to Mrs. Surprise, who does not yet know that she has HIV?
 

CASE ONE CONTINUED

You inform Mrs. Surprise of her newly diagnosed HIV infection, using the SPIKES method. Mrs. Surprise states that she was last sexually active about 4 years ago, with a partner whom she believes gave her HIV. She denies drug use or prior blood transfusion. Her only family member is her daughter. She asks that the medical team do not tell her daughter of the HIV diagnosis.

CASE TWO

Mr. Newlove is a 62 year-old homosexual man with HIV, well-controlled on elvitegravir, cobicistat, emtricitabine and tenofovir. He also has a history of hypertension, well-controlled on metoprolol 25 mg daily, and depression on venlafaxine 75 mg daily. During a regular follow-up visit, Mr. Newlove divulges that he is starting to go out on dates again, after ending a long-term relationship with his partner 9 months ago.

5. What questions would you ask to assess Mr. Newlove’s sexual health and behaviors?

CASE TWO CONTINUED

Mr. Newlove admits to an inability to achieve and sustain an erection that is adequate for sexual function. He also mentions that his new love interest is a 58-year-old homosexual man without HIV, and Mr. Newlove is concerned about preventing HIV transmission to his new partner.

6. What are age-related changes in sexual function in men? In women? What are common reactions to these changes?

7. How would you approach Mr. Newlove’s erectile dysfunction?

8. How do you counsel Mr. Newlove about preventing HIV transmission to his uninfected partner? Would you recommend preexposure prophylaxis (PrEP)? How do you counsel Mr. Newlove about PrEP and how would you monitor the treatment?