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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 CDC provides clinical guidelines recommending PrEP as an evidence-based intervention to prevent HIV transmission (CDC 2014c). Multiple clinical trials have demonstrated the efficacy of PrEP (Treston 2015; Caceres 2015). In 2012, the Food and Drug Administration approved tenofovir + emtricitabine (TDF/FTC, Truvada) for use as PrEP in adults (CDC 2014c). 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 (Volk 2015).
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.... 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).
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 (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.
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.
CDC. US Public Health Service PrEP for the Prevention of HIV Infection in the US – A Clinical Practice Guideline. 2014.
CDC. Diagnoses of HIV Infection in the United States and Dependent Areas, 2013. 2015,25.
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_a...
Karpiak S, Lunievicz J. Age is Not a Condom: HIV and Sexual Health for Older Adults Current Sexual Health 2017 (Springer Science)