HIV PrEP for Older Adults

In this podcast, Jeffrey Kwong, DNP, MPH, ANP-BC, discusses the use of HIV pre-exposure prophylaxis (PrEP) in older adults, its safety and efficacy in this patient population, and what barriers exist for people who are interested in using PrEP later in life.

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Jeffrey Kwong, DNP, MPH, ANP-BC, is a professor in the division of advanced nursing practice at Rutgers School of Nursing (Newark, New Jersey). 


Jessica Ganga: Hello everyone and welcome to another installment of Podcast 360, your go-to resource for medical news and clinical updates. I'm your moderator, Jessica Ganga with Consultant360, a multidisciplinary medical information network. According to the most recent data from the Centers for Disease Control and Prevention in 2019, nearly 4,000 people aged 55 years or older were diagnosed with HIV in the United States. Here with us today to talk about HIV preexposure prophylaxis in older adults is Dr Jeffrey Kwong, who is a professor in the division of advanced nursing practice at Rutgers School of Nursing. Thank you for joining us, Dr Kwong.

Dr Jeffrey Kwong: Thank you very much, Jessica, for having me today.

Jessica Ganga: Of course. Let's dive into the first question. Over the past 20 years, there has been an increase in HIV AIDS diagnoses in older adults. Why do you think that is?

Dr Kwong: Sure. That's a really great question. I think there are several factors that really come into play here. One is really this, I think increased uptake in the recommendations, both from the Centers for Disease Control and Prevention [CDC], as well as the US Preventative Services Task Force [USPSTF] that emphasize universal screening and testing for persons, regardless of perceived risk between the CDC says 13 to 64. The USPSTF says 15 to 65 as part of routine testing and routine primary care. So I think just the fact that people are more aware of testing has led to an increase in diagnosis and identification of cases, which is really part of the goal.

And I know you're going to probably ask me this a little bit later, but I think this relates to it somewhat, which is actually in New York state, which is where I practice clinically, they revised the guidelines a couple of years ago and they took off the upper age limit. So now they just say 13 and older. And part of the reason for that was that they found that clinicians and providers thought, oh, well, 65, I'll just stop testing at 65, because that's what the guidelines say. But we know in fact that people over 65 may still be at risk for STIs and HIV. And so they took that upper limit off, which I think is a really forward-thinking move on the part of New York state in terms of trying to help identify people who may not know their diagnosis who are older adults, so.

Jessica Ganga: And that's a good segue to the next question. What are the common misconceptions about HIV PrEP in older adults?

Dr Kwong: Sure. I think one of the biggest misconception or misperceptions, I should say, is that older adults are not at risk for HIV period; that people think that older adults don't have sex. They don't engage in activities that may put them at risk for HIV. And I think that is one of the biggest barriers that clinicians in all different practice settings really need to kind of understand. And we as a culture and as a society really need to address as healthcare professionals to recognize that older adults are still sexual in their older adult hood. And here, when I say older adulthood, I mean 65 plus really that people still engage in sex.

And if you look at the statistics, if you look at the data from the CDC, we know that in fact, although the bulk of new infections are occurring in people who are in their 20s and 30s, about 16% of new HIV infections are occurring in people 50 years and older. And so when we think about misconceptions about HIV PrEP, people don't think that people who are 50 years or older need to worry about HIV prevention when in fact they do. And I think that is one of the things that poses a barrier because people don't think that people are at risk and therefore they don't bring it up. And they think PrEP is only for younger adults or it's only for men who have sex with men and they don't consider a person that's sitting in front of them as a potential candidate for PrEP.

Jessica Ganga: And when we're talking about the use of PrEP, what is the efficacy and safety of PrEP in people older than 50 years of age? And then how does it compare with people younger than 50 years of age?

Dr Kwong: So this is a really also very interesting question because when we look at the data from registrational trials, looking at the efficacy and benefit of PrEP, there's actually very limited data or that I should say the studies that were used to prove the efficacy of PrEP have been very limited in terms of including older adults. So one of the earlier trials, there's the iPrEx trial, which was one of the very first ones. There's Partners PrEP, there's the IPERGAY trial, and the discover trial that looked at the use of the primary 2 oral agents that we use for PrEP in the United States currently. And if you look at the patient population that they studied, only a fraction of individuals were even over the age of 40. Some of them had hardly anybody over 50. So when we look at the data, you think, well, there's not a lot of data for older adults, but it was FDA-approved for people and they don't put an age limit on it.

And I think that holds true regardless of what product or what intervention. Many trials typically exclude older adults from their clinical trials because of many reasons. But if we look at medications themselves, just in terms of overall safety, we use these same medications for prevention that we use for HIV treatment. And so if we sort of extrapolate some of the information, there is more data and more information on the use of these medications in older persons living with HIV. So we know that these medications are indeed safe and we do use them in people who are 50, 60, 70, or 80 plus. Right. And we know that in terms of safety, these medications are safe. It's just that when you look specifically at the trials that were submitted for FDA approval, there's just, there's very limited data on that.

So the most recent PrEP option that became available, which is a long-acting injectable therapy called Cabotegravir. In the HPTN 083 trial, which was studied and looked at men who have sex with men and transgender women, that study actually did have a small percentage of older adults. Actually it showed, or they included 0.3% of the patients enrolled were 60 years or older. So for that particular product, which is long-acting injectable Cabotegravir, there is some data in older adults, which again, that trial showed that the medication was safe and effective in there so.

Jessica Ganga: Thank you for having that up. Always great to have the statistics there. Still talking about the use of PrEP, can you talk about any adverse effects that can occur when older adults choose to use it?

Dr Kwong: Sure. Now, this is, I think one of the more challenging aspects about PrEP and considering which options are best options for older individuals. So when we think about the three FDA-approved options that are available now in 2022, there are two oral formulations and one injectable long acting formulation. The two oral formulations potentially have side effects that include impact on kidney function, bone mineral density, as well as potentially lipid profile and weight. And so if you look at those factors, just kidney and bone alone, we know that older adults also can be prone to renal disease as they age or renal dysfunction, as they get older. We know that there are issues with just osteoporosis and osteopenia or bone thinning as people age in general. So when we think about PrEP and potential side effects, now again, the side effects that I mentioned of kidney, bone, and even lipid issues don't occur that frequently, but they are something that should be considered when thinking about prescribing or thinking about administering these options to older individuals over the long term.

So one of the primary ones, TDF FTC has a renal dose restriction on it. It's sort of sister drug, if you will, TAF FTC, that's tenofovir alafenamide and emtricitabine, you can use in people with creatinine clearances less than down to 30. So it has to be 30 or over. So in those individuals, there are some options. If people may have some co-occurring conditions where these medications can still be used, but nonetheless, those are some things that we need to counterbalance. So if somebody has kidney disease, maybe the TDF or the TAF one's not the best option and they should use the injectable option, because that does not have the same kidney or bone issues as you might see in the oral formulations.

Jessica Ganga: And I think you touched briefly upon this in the beginning of the conversation, but can you elaborate a little bit more? What are the systemic barriers for PrEP uptake in older adults and how can we begin to address them?

Dr Kwong: Sure. So one of the big systemic barriers that I alluded to at the beginning of our conversation is the fact that clinicians, primary care, and women's healthcare, and specialty practices aren't asking or assessing their patients about potential HIV risk. So I think that's one barrier. So from the provider's standpoint, clinicians just don't feel comfortable talking about sexual health with older adults, or it gets trumped by other issues that patients come in with in addition to their diabetes and their hypertension and their cholesterol issues, sexual health sort of falls to the bottom of the list for many clinicians. There actually was a study, I'm sort of sidetracking here, but it's pertinent where they looked at older adults and sexual health in their primary care experiences. And they found that again, only a fraction, I think it's less than 20% of clinicians brought up sexual health in a clinic visit with an older adult and here 65 and older. And in the situations where people had sexual health issues brought up or talked about the majority of the time, it was brought up by the patients themselves and not the providers.

And so again, when we think about systemic barriers, that's one that patients, I mean, that providers aren't asking. The other thing that I think when we think about systemic barriers is cost and insurance. I think many people don't know or are concerned about cost of medications. Thankfully, now there is a generic formation of one of the oral PrEP options. So most insurances should cover at least the oral PrEP options for most people. Other things that kind of come up here when we think about systemic barriers is just culture and cultural perceptions of HIV and the stigma of taking something that is considered an HIV medication. So although we use this for prevention, people still have the perception that, oh, I'm taking an HIV medication. Will people think that I have HIV if somebody sees it in my medicine chest or do I have to explain it to my son or my daughter or my children or my other caretakers or whoever that I want to take PrEP and what does that bring up?

Dr Kwong: And there's that whole sort of communication cultural dynamic that comes up that I think plays a role in terms of barriers for PrEP uptake. I would say those are probably some of the key drivers around that. And also I would just say that people don't know that it exists again as an option because they see ads for PrEP, but if you look at the images that are portrayed in the ads specifically for PrEP medications, they're mostly younger adults in those ads. So there's diversity in terms of gender in the ads for PrEP, there's diversity in terms of racial and ethnic representation in the ads for PrEP. But I don't see a lot of ads for prep that include images of people who are older. And I think that consciously or unconsciously provides a barrier to making it accessible or something that people who were older can relate to because they don't see themselves specifically in these images for this intervention or this product.

Jessica Ganga: What would you say are the gaps in the research of PrEP among older adults?

Dr Kwong: Sure. So when we think about gaps in research, I think there are quite a few areas to explore. And some of these things I would love to delve into myself. I mean, once again, as I mentioned, just in terms of specifically the clinical trial data that was used for approval, didn't include a lot of older adults. So I think looking even if it's retrospective study of looking at A the uptake, B the long-term side effects, and C the efficacy of PrEP in older adults, I think that's one area that's very rich for data mining and discovery. I also think areas of research that we don't really understand is the impact of PrEP in terms of just overall behavior change. We know that in terms of PrEP and how the CDC recommends using PrEP, PrEP is only protective against HIV. It doesn't protect against other STIs.

And the guidance suggests that people should use PrEP in combination with other barrier methods to protect against gonorrhea and chlamydia and syphilis, et cetera. Now, we do know that rates of STIs like gonorrhea, chlamydia, and syphilis have increased dramatically in older adults because people, again don't think that they need to use any barrier protections because individuals who may identify as heterosexual think, oh, well, barrier protection is only to prevent against contraception issues and fertility issues. And now I'm an older adult. I really don't need to use barrier protection. And so people don't necessarily use barriers for sex as they get older. And we know that there is in at least younger adults, what some have called risk compensation, where people who are younger may voluntarily choose not to use condoms because they feel like, this thing that's not quote-unquote curable at this point is HIV. And now that I have something that protects me against HIV, I'm not going to use condoms.

Dr Kwong: It changes some of the behaviors that people used to use. So, meaning, that people stop using condoms. So with older adults, I wonder if there's any, that same mindset. If people are like, I'm not going to use condoms or I'm going to use barrier protection more now because I'm more aware of STIs and risk than they were before. So I think that's one area to explore in terms of research gaps is behavior change in terms of that. I also think just in terms of now, again, thinking about older adults who may have multiple comorbidities, I don't know how much data we have just in terms of managing well, who have diabetes, heart disease, cancer, and liver disease and PrEP. Again, typically the data has been in younger individuals without a lot of comorbidities, but we know in the older population, people have 4, 5, 6 comorbidities. And what is the impact of PrEP and PrEP, medications long term in these settings, so.

Jessica Ganga: And what do you believe is next for research on PrEP in older adults?

Dr Kwong: Well, when we think about kind of new advances in PrEP, one of the big things that's coming up is this era of long-acting, long-term PrEP medications that don't have to take daily and similar to long-acting reversible contraceptives that we use, where people can get an injection or even an implant that can last for months and months, there is research that's underway looking at PrEP medications that can last months, three months, six months at a time. And that reduces the pill burden that people have to take a pill every day.

We know that one of the geriatric syndromes that occurs as people age is polypharmacy, meaning people have to take multiple pills. So when we think about if there's an option where people don't have to take pills and they can just do something twice a year and get an injection at their primary care site, and it reduces the risk of polypharmacy and drug connections, I think that's something to explore and to look at. I mean, we're seeing some of that now with the Cabotegravir where it's every two months, but extending that to every six months or longer, I think is really exciting and something to look forward to.

Jessica Ganga: What are the overall take-home messages for clinicians from our conversation today?

Dr Kwong: So, if I had to summarize and say, what are some of the key take homes that I would like every clinician to hear or to take away from this specific conversation today I would say one, please consider or remember that older adults are still sexual beings, can still be at risk for HIV. And to really open the door and have that conversation to identify if the person that's sitting in front of you could benefit from this truly lifesaving preventive intervention. That's probably the key take-home. The other thing that I would emphasize from this is the importance of early detection and testing.

And so even if somebody may not necessarily feel that PrEP is appropriate for them, what we really need to do is to continue that conversation, to test for HIV. Because from our very first question, we know that there are individuals who may not be identified early in terms of their HIV diagnosis and can have untreated HIV for many years and have poor outcomes. So one of the federal initiatives of ending the HIV epidemic includes earlier testing and identification of individuals. So I would say second key point is to make sure that you're offering testing, that you're screening individuals. Again, even if they don't need PrEP or want PrEP, if you can at least do and screen for HIV, that is a step in the right direction.