HIV Prevention for Older Adults: PrEP

What is PrEP?

PrEP stands for Pre-Exposure Prophylaxis. “Prophylaxis” (pronounced pro-fil-ak-sis) means to prevent or control the spread of an infection or disease. The goal of PrEP is to prevent HIV infection if you are exposed to the virus. PrEP is a pill (Truvada) that contains 2 HIV medications, It is taken once a day. Truvada is also used to treat HIV.

Why take PrEP?

The HIV epidemic in the United States is growing. About 38,000 people get HIV each year. Older adults get the virus in the same way as younger people.

50% of people living with HIV are over the age of 50 and 17% of new HIV  infections occur in people over 50.

Should I consider taking PrEP?

You should consider PrEP if you sometimes have sex without a condom, especially if you have a sex partner who has HIV. You should also consider PrEP if you don’t know whether your partner has HIV but you know that your partner is at risk for it (for example, your partner injects drugs or is having sex with other people in addition to you), or if you have recently been told by a health care provider that you had a sexually transmitted infection.

If your partner has HIV, PrEP is an option to help protect you from HIV.

How can I start PrEP?

If you think you may be at risk for HIV, talk to your doctor about PrEP. If you and your doctor agree that PrEP might reduce your risk of getting HIV, you will need to come in for a general health physical, blood tests for HIV, and tests for other infections that you can get from sex partners. Your blood will also be tested to see if your kidneys and liver are functioning well. If these tests show that PrEP medicines are likely to be safe for you, your doctor may give you a prescription after discussing it with you. Taking PrEP medicines will require you to follow-up regularly with your doctor.

If I take PrEP can I stop using condoms when I have sex?

You should not stop using condoms because you are taking PrEP.  If PrEP is taken daily, it offers a high leverl of protection against HIV, but not 100%. Condoms also offer protection against HIV infection if they are used correctly every time you have sex, but no method is 100% effective.

PrEP medications don’t give you any protection from other infections you can get during sex, but condoms do. So you will get the most protection from HIV and other sexual infections if you consistently take PrEP and consistently use condoms.

How long do I need to take PrEP?

You should discuss this with your doctor. If you find you don’t want to take a pill every day or often forget to take your pills, other ways of protecting yourself from HIV infection may work better for you. If you have side effects from the medication that don’t go away after a few weeks or if blood tests show that your body is reacting to PrEP in unsafe ways, your doctor may stop prescribing PrEP for you.

Should Older Adults Be Taking HIV PrEP?
Weighing the Pros and Cons of the HIV Prevention Pill

By Dennis Sifris, MD and James Myhre

(adapted from an article at www.verywell.com)

Today roughly 21% of all new HIV diagnoses are among older adults, and a quarter of these are over 60.  We tend to assume that people over the age of 60 don’t have healthy, and even robust, sex lives.  That’s clearly not true.

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

PrEP (the once-daily pill Truvada) offers a means to protect against HIV. 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 For Seniors

In an editorial in the May 2016 issue of The Advocate, Stuart Sokol, a gay senior, offered his perspective as to whether seniors and PrEP were as appropriate a mix.  He 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 would cover PrEP, 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?"

In 2015, the CDC reported that 34% of primary care 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 to ensure doctors that PrEP care should be a part of primary care.

Arguments in Support of PrEP in Seniors

  • As many as 20% of people over 50 engage in high-risk insertive sex, whether anal or vaginal.
  • Condom use tends to decrease as one gets older, from 24% in people in their 50s to 17% in people in their 60s.
  • 62% of men and 78% of women have never discussed their sexual health with a doctor since turning 50.
  • Several studies have shown that older males often do not use condoms due to the inability to sustain an erection.
  • Many older women believe neither they nor their partner need a condom because they are post-menopausal.

Avoiding HIV becomes even more imperative in older adults given their high number of co-existing medical conditions. And, newly infected seniors typically have lower CD4 counts at the time of diagnosis, as well as having a steeper CD4 decline and more rapid disease progression.

Together, these issues support the use of PrEP, if only to avoid the complications of infection and treatment in older adults. Ultimately, it is personal choice—made with full, unbiased information—that will determine whether PrEP is the right choice for you.

Latest Data on PrEP

The CDC estimates that there are as many people at risk of acquiring HIV as there are people estimated to be living with HIV. Though the numbers of persons at risk for HIV remain elevated, the percentage of those at-risk varies by population.​

The CDC estimates that overall, an estimated 1,232,000 adults (CI = 661,000–1,803,000) have substantial risk for HIV acquisition, for whom PrEP and other effective prevention methods are indicated.​

High proportions of MSM and IDU remain at risk for HIV.​

Though the proportion of heterosexuals at risk is low, the absolute numbers remain large nationwide, particularly among women​

(NOTE: MSM and women rows are bolded to show similar absolute numbers.)​

The number of men aged 18–59 years not known to be HIV-positive who reported sex with a man in the past 12 months was derived from National Health and Nutrition Examination Survey (NHANES) data from 2007–2008, 2009–2010, and 2011–2012 combined.​

The number of these MSM reporting sex with two or more men in the past 12 months and any condomless sex or sexually transmitted infections in the past 12 months was used to calculate the percentage of HIV-negative sexually active adult MSM with behavioral indications for PrEP use. This percentage was weighted as recommended for NHANES data using current population estimates of the population of men aged 18–59 years to yield an estimate of the number of U.S. MSM with indications for PrEP. Estimates of MSM with indications for PrEP did not consider injection risk. ​

The number of persons aged ≥18 years who reported in the National Survey on Drug Use and Health (NSDUH) (2013) having injected any assessed drug during the past 12 months and used a needle that had previously been used by another person was used to yield an estimate of the number of U.S. persons who inject drugs with indications for PrEP use. The estimate for persons who inject drugs did not consider sexual risk or HIV infection status. ​

The number of men and women aged 18–59 years not known to be HIV-positive was derived from NHANES data from 2007–2008, 2009–2010, and 2011–2012 combined and was used to calculate the percentage of HIV-negative adults among NHANES respondents. This percentage was weighted, as recommended for NHANES data, using current population estimates of the population of men and women aged 18–59 years to yield an estimate of the number of HIV-negative adults. ​

Next, National Survey of Family Growth data (2011–2013) were analyzed to identify the number of men and women aged 18–44 years who reported sex with two or more opposite sex partners and either of the following: 1) sex with an HIV-infected partner; or 2) any condomless sex in the last 4 weeks and sex with a high-risk partner in the past 12 months. High-risk partners were defined as persons who inject drugs or (for women) male partners known to also have sex with men (behaviorally bisexual). ​

The percentage of heterosexually active adults aged 18–44 years with behavioral indications for PrEP use in the National Survey of Family Growth was multiplied by the estimated number of HIV-negative adults aged 18–59 years from NHANES to yield an estimate of the number of heterosexually active adults in the United States with indications for PrEP. Estimated heterosexually active adults with indications for PrEP did not consider injection risk. Bisexual men were assessed by indications for both MSM and heterosexually active adults and added to the populations for which PrEP indications were met.

 

 

Abbreviation: CI = confidence interval.​

*Percentage of all estimated persons in each transmission risk group and demographic subset with PrEP indications.​

†Based on 2007–2012 National Health and Nutrition Examination Survey (NHANES) data, weighted as recommended using current population estimates. Risk factors used to define PrEP indications included two or more male sex partners and at least one of the following: any condomless sex or sexually transmitted infection diagnosis in past 12 months.​

§Based on 2013 National Survey on Drug Use and Health. Risk factors used to define PrEP indications included injection of heroin, methamphetamine, stimulants, or cocaine, and injecting with a needle used by someone else before them.​

¶Based on 2011–2013 National Survey of Family Growth and 2007–2012 NHANES data, weighted as recommended using current population estimates. Risk factors used to define PrEP indications included two or more opposite sex partners and at least one of the following: sex with an HIV positive partner; or any condomless sex in the last 4 weeks and sex with a male who injects drugs or bisexual male (females only) in last 12 months.​

**The relative standard error for males was 30.09%.​