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Clinical Affiliate Assistant Professor
Department of Integrated Medical Science
Charles E. Schmidt College of Medicine
Florida Atlantic University
Boca Raton, Florida
Medical Director, West Palm Beach, Wilton Manors, and Key West
Midway Specialty Care
Wilton Manors, Florida
Howard Grossman, MD, has disclosed that he has received consulting fees from Gilead Sciences; has received fees for non-CME/CE services from Gilead Sciences and ViiV Healthcare; and has ownership interest in Esperion, Gilead Sciences, Pfizer, and ViiV Healthcare.
Head of Department of Infectious Diseases and Tropical Medicine
Full Professor of Infectious Diseases
Infectious Diseases Clinics, University Hospital
University of Modena and Reggio Emilia
Cristina Mussini, MD, has disclosed that she has received consulting fees from AbbVie, Angelini, Gilead Sciences, Janssen, MSD, and ViiV Healthcare and funds for research support from Gilead Sciences, Janssen, MSD, and ViiV Healthcare.
How can we increase HIV diagnosis and prevention in older individuals?
Cristina Mussini, MD:
Due to the COVID-19 pandemic, we see mostly patients presenting with late-stage HIV. It seems as if getting tested for HIV is perceived as less important now. At my institution in Italy, approximately 80% of our newly diagnosed patients were severely ill. Getting tested for HIV is based on a person’s perception of his or her own risk, and this perception varies widely. Some people perceive themselves at extreme risk with 2 sexual partners, whereas others do not perceive themselves as high risk with 100 partners.
For example, men who have sex with men tend to present with late-stage HIV less often because they have a higher perception of risk (but not always). We also have many heterosexual migrants who acquire HIV in Italy. They arrived in Italy without HIV and with a low perception of risk but then later discover that they acquired HIV in Italy. Better diagnoses of HIV-associated illnesses could indicate to healthcare professionals that they should request an HIV test. Patients who have not yet progressed to AIDS may have herpes zoster, hepatitis, or lymphoma. Overall, we need to start screening people earlier for HIV.
Howard Grossman, MD:
Increasing numbers of persons older than 50 years are presenting with late-stage HIV disease. However, there are often no prevention services specifically targeting persons older than 50 years of age.
I think we must make HIV testing a standard practice, regardless of perceived risk, the same way we check blood pressure. In this way, we will be able to include all patients who are at risk. Most places in the United States have opt-out testing. In our facility, we have signs in all patient examination rooms stating that we test everybody for HIV—it has become our standard practice whether you come for a physical or if you come as a new patient. If people opt out, they simply tell us they do not want to be tested.
I think that many people older than 50 years currently at risk may not have directly experienced the HIV epidemic, so they may have a lower perceived risk. For example, I recently saw a 53-year-old man who is just coming out. He really had no previous contact with the gay community, was living in a suburb, and is just learning his way. Again, he should be tested regardless of perceived risk.
Men who have sex with men aged in their 50s and 60s who have survived all these years and think that they have been doing everything right represent another group that often perceives their risk as low but should be tested for HIV. In my experience, once they begin having erectile problems, they stop using condoms. They are also often are not receiving pre-exposure prophylaxis (PrEP), so they are at risk.
What are your experiences prescribing PrEP in aging patients, and are there any special considerations or concerns for patients older than 50 years?
Howard Grossman, MD:
I think our biggest concern is that many patients older than 50 years have compromised renal function. Tenofovir alafenamide (TAF) has a better renal profile and can be prescribed for patients with a glomerular filtration rate (GFR) >30 mL/min. However, I do have some patients with renal function below that GFR, and although intermittent or on-demand PrEP is not approved or recommended in the United States, it is something I have used successfully with some of these patients. Patients who are 75 or 80 years of age usually plan their sexual activity. They can take the 2 pills between 2 and 24 hours ahead of time and then take 1 pill each day over the next 2 days. This regimen fits with the way that they have sex, and it does not compromise their renal function as much. However, now that tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC) is available in generic form, many insurance companies are only covering this TDF-based PrEP. We have to advocate for patients to get TAF/FTC if they have renal or bone concerns.
Your Thoughts?What HIV testing and prevention strategies do you think are needed to better prevent HIV in older individuals? Please answer the polling question and join the discussion in the comments section.