Should Older Adults Take HIV PrEP?

It would probably surprise few that the rate of new HIV infections among adults over the age of 50 is significant and growing. Today roughly 21% of all new HIV diagnoses are among older adults, of which a quarter of these are among seniors aged 60 and over.

A man taking his medicine while sitting on the bed

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While one might assume that the popularity of erectile dysfunction drugs like Viagra or Cialis is fueling these high transmission rates, the simple fact is that we, as a society, tend to assume that people over the age of 60 and 70 don’t have healthy, and even robust, sex lives. And that’s clearly not true.

As such, doctors often fail to discuss safer sex with their older patients or even query them about their sexual practices. Provider discomfort combined with misconceptions about HIV risk among some older adults ends up leaving far too much unspoken.

In recent years, the availability of HIV pre-exposure prophylaxis (PrEP) has offered at-risk individuals a means to better protect themselves from infection. Approved by the U.S. Food and Drug Administration in 2012, the once-daily pill strategy has been shown to reduce the risk of HIV by around 96% in certain high-risk populations.

Based on this, current guidance from the U.S. Public Health Services (USPHS) recommends that any person at "substantial risk of infection" be provided PrEP as part of a comprehensive HIV prevention strategy. And that includes older adults, whether heterosexual, bisexual, or homosexual.

Yet despite government efforts to increase PrEP uptake, many older adults remain uncertain as to whether it is right for them, often citing medication cost or the burden of daily drug adherence as key barriers. Others, meanwhile, believe themselves adequately protected by condoms or by sexual activities considered to be of lower risk.

To others still, PrEP is an option they believe needs to be weighed objectively and on an individual basis, measuring the potential benefits against potential consequences.

An HIV Advocate Questions PrEP Use in Seniors

In an editorial in the May 2016 issue of Advocate, Stuart Sokol, a 71-year-old, HIV-negative gay man who served as supervisor for both the National AIDS Hotline and the Los Angeles County Commission on HIV Health Services, offered his perspective as to whether seniors and PrEP were as appropriate a mix as some health officials suggest.

"Despite the current practice to get the newly infected on medical treatment," argued Sokol, "we know it takes years from the initial exposure to HIV until the first symptoms make themselves known. This could be as long as from eight to 12 years, or even 15."

"Those dates would put me into my 80s," Sokol continued, adding, "Absolutely, if I were in my 20s, 30s, 40s, 50s or 60s, I would jump on the opportunity, but in my 70s, I’m not sure."

Sokol further questioned whether people of his age group, who may likely have medical concerns that require regular check-ups and lab tests, would be willing to submit to additional blood tests to monitor both their HIV status and possible drug side effects. And while Medicaid and most health insurance policies would cover PrEP in their drug formularies, the co-payments and deductibles could alone be prohibitive for some.

Sokol also cited a lack of knowledge among clinicians as a problem facing many in need of information about PrEP benefits and drawbacks.

"Neither my primary care doctor nor my urologist was forthcoming about their thoughts (regarding PrEP)," said Sokol. "They either warned against side effects or suggested the HIV clinic. Really?"

Research tends to support Sokol’s claim. In 2015, the Centers for Disease Control and Prevention (CDC) reported that 34% of primary care health providers in the U.S. had never even heard about PrEP. Of those who did, many referred patients to specialist treaters despite efforts by the CDC and USPHS to ensure doctors that PrEP care could—and should—be administered within the aegis of primary care.

Even among HIV-specific practices, there still remains a reticent to implementing PrEP in patients, with only 17% reported ever having prescribed the drug.

(Overall, consumer uptake in the U.S. remains modest, with some studies suggesting that between 22,000 and 25,000 Americans may currently be on PrEP.)

Arguments in Support of PrEP in Seniors

Despite lagging figures, PrEP usage was nearly four times higher among people in their mid- to late-40s than those in their 20s, suggesting that older age (as well as income, attitudes, and a greater awareness of preventive health in general) offered fewer barriers to treatment.

Supporters of PrEP further point sexual attitudes and practices that can place many seniors at higher risk of infection. Among the concerns:

  • Research suggests that as many as one-in-five adults over the age of 50 engage in high-risk insertive sex, whether anal or vaginal.
  • Condom use tends to decrease as one gets older, from 24% in persons aged 50 to 59 to as little as 17% in persons aged 60 to 69.
  • 62% of men and 78% of women have never discussed their sexual health with a doctor since turning 50.
  • A number of studies have shown that older males often do not use condoms due to the inability to sustain an erection.
  • Additionally, many older women with HIV believe neither they nor their HIV-negative partner needs a condom because they are post-menopausal.

Avoiding HIV becomes even more imperative in older adults given the high incidence of co-existing medical conditions when compared to younger populations. Furthermore, newly infected seniors typically have lower CD4 counts at the time of diagnosis, as well as having a steeper CD4 decline—conferring to more rapid disease progression.

HIV therapy can also be complicated in older adults as they are more likely to be treated for other conditions such as high blood pressure, cardiovascular disease, lung disorders, and diabetes. This translates to a higher risk of drug-drug interactions, as well as complications related to dosing schedules and drug adherence.

Together, all of these issues support the use of PrEP, if only to avoid the complications of infection and treatment in older adults.

Making the Right Choice for You

Whether PrEP is appropriate for you is something you and your doctor need to decide on an individual basis, with full disclosure of both the pros and cons of use based on your personal circumstances and risk. What it certainly is not is a one-size-fits-all solution.

It should also be remembered that PrEP is not meant to be a stand-alone tool. Condoms, a reduction in the number of sex partners, and the use of antiretroviral therapy in the HIV-positive partner should all be explored as part of cohesive prevention strategy.

"I love the idea that there are solutions that can work,” said Sokol. “I am 100% for it. Yet I need to consider if (PrEP) is right for me."

Ultimately, it is a personal choice—made with full, unbiased information—that will determine whether PrEP is the right choice for you. Speak with your doctor or contact your regional AIDS hotline for more information or referrals to a specialist nearest you.

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