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HIV & Aging Clinical Recommendations
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:
The Centers for Disease Control and Prevention (CDC) provides clinical guidelines recommending PrEP as an evidence-based intervention to prevent HIV transmission (CDC 2017). Multiple clinical trials have demonstrated the efficacy of PrEP (Treston 2015; Caceres 2015).
There are two FDA approved options for PrEP. In 2012, the Food and Drug Administration approved tenofovir disoproxil fumarate + emtricitabine (TDF/FTC) for use as PrEP in adults (CDC 2017). This regimen consists of one pill taken once per day. When taken consistently, it has demonstrated a high level of protection against HIV infection. In 2019 tenofovir alafenamide + emtricitabine (TAF/FTC) was also approved as an option for PrEP in adults at risk for HIV infection. TAF/FTC is not approved for persons who are female assigned at birth who are at risk of acquiring HIV through vaginal sex. (Descovy 2021)
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 (Volk 2015). Often there is assumption that everyone is aware of PrEP. But repeated studies show that PrEP awareness is low. In a 2021 study derived from an at-risk sample in the Southern Tier of the USA, less than 20% had heard of PrEP (Towe 2021).
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. (McManhus 2020)
TDF/FTC should not be used in persons with a CrCl < 60 ml/min. TAF/FTC may be used in persons with CrCl ≥30 ml/min. Both options require ongoing monitoring of HIV status, renal function, and screening for other STIs.
The CDC does not recommend routine DEXA screens before initiating PrEP (CDC 2017).
Reasons to support PrEP use in older adults:
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. Use of PrEP is associated with accessibility. MSM access PrEP at high rates in states which have embraced Medicaid expansion (Baugher 2021).
A seminal study found that 18% of older adults with HIV were engaging in condomless sex with HIV-negative partners (Golub 2010). Although older adults often have sexual relations more with age-matched peers (Slater 2015), several studies have shown that there is a significant amount of high-risk behavior occurring between younger and older individuals (Mustanski 2013; Coburn 2010). For the older adult with HIV who is having sex with a younger person, the opportunity to encourage the use of PrEP is evident. Data on this axis of older and younger MSM is not available.
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) (NYS 2016) addresses PrEP in the context of older adults living with HIV. The report details reasons for offering PrEP to older adults:
The report (NYS 2016) 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 (Karpiak 2017).
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.
McManus H et al. Renal impairment in a pre-exposure prophylaxis implementation cohort in Australia. Conference on Retroviruses and Opportunistic Infections, abstract 1004, March 2020.
Towe SL, Sullivan CA, McKellar MS, Meade CS. Examining the Potential of Pre-exposure Prophylaxis (PrEP) for HIV Prevention in a Community Sample of Persons Who Use Stimulants Living in the Southern United States. AIDS and Behavior 2021 May; 25:1480–1489.
CDC Updated Edition, Volume 31: Diagnoses of HIV Infection in the United States and Dependent Areas, 2018 Home American Journal of Public Health (AJPH) April 2021
Baugher AR, Finlayson T, Lewis R, Sionean C, Whiteman A, Wejnert C. Health Care Coverage and Preexposure Prophylaxis (PrEP) Use Among Men Who Have Sex with Men Living in 22 US Cities With vs Without Medicaid Expansion. Home American Journal of Public Health. Am J Public Health 2021 Apr;111(4):743-751. doi: 10.2105/AJPH.2020.306035. Epub 2021 Jan 21.
HIV Annual Surveillance Report 2019. New York City Dept of Health.
Santos GM, Miller D, Jain J, Gyamerah A, Wilson E, McFarland W, Raymond HF. Prevalence and Correlates of Methamphetamine Use Among Older Men Who Have Sex with Men in San Francisco. Generations Journal 2021 Winter. Available Online: [https://generations.asaging.org/meth-use-among-older-men-who-have-sex-me.... Retrieved: May 3, 2021.
Purpose of this Program: The AAHIVM, ACRIA and AGS (collectively, the “Sponsors,” “we” or “us”) are sponsors of this Website and through it seek to address the unique needs and challenges that older adults of diverse populations living with HIV face as they age. However, the information in this Website is not meant to supplant the advice provided in a doctor-patient relationship.
General Disclaimer: HIV-Age.org is designed for educational purposes only and is not engaged in rendering medical advice or professional services. The information provided through HIV-Age.org should not be used for diagnosing or treating a health problem or a disease. It is not a substitute for professional care. If you have or suspect you may have a health problem, consult your health care provider.