HIV/AIDS: An Update ________________________________________________________________________
individuals to live long, healthy lives, increasing the number of older people living with HIV. Due to the large proportion of older people with HIV, evidence points to the increasing need for change in prevention and education campaigns [26]. While many risk factors are the same for people of any age, older individuals present with several unique factors that should be considered. For example, older people in general may have less knowledge about HIV and risk reduction strate- gies. Due to divorce or being widowed and the availability of medications to treat erectile dysfunction, increasing numbers of older people are becoming sexually active with multiple partners. For postmenopausal women, contraception is no longer a concern, and they are less likely to use a condom. Furthermore, vaginal drying and thinning associated with aging can result in small tears or cuts during sexual activity, which also raises the risk for infection with HIV. Women and men in this age group are significantly less likely than younger at-risk adults to use condoms during sex. In addition, health- care professionals are less likely to discuss sexual activity, take a sexual history, and/or recommend testing for HIV if the patient is older. The combination of these factors increases the risk for unprotected sex with new or multiple partners in this age group, thereby increasing their risk for HIV. These factors should all be considered when evaluating older patients [26]. Early possible signs of immunosuppression that are frequently overlooked or mistakenly attributed to aging include thrush and skin problems, especially seborrheic dermatitis and her- pes zoster. When HIV is not recognized or treated, the most typical opportunistic infections are PCP and recurrent bacte- rial pneumonia, CMV, and Mycobacterium tuberculosis or Mycobacterium avium complex. PCP can present as bacterial pneumonia, bronchitis, or congestive heart failure. Early HIV symptoms in the elderly, such as fatigue and weight loss, may appear to be a normal part of aging, and AIDS-related dementia is often mistaken for Alzheimer disease [26]. The Panel on Antiretroviral Guidelines for Adults and Adolescents asserts that polypharmacy is common in older people with HIV, and all drugs, supplements, and herbal treatments should be assessed regularly for appropriateness, potential for adverse effects, proper dosing, and drug interactions. (https://clinicalinfo.hiv.gov/sites/default/files/ guidelines/documents/adult-adolescent-arv/guidelines- adult-adolescent-arv.pdf. Last accessed March 21, 2025.)
HIV/AIDS PREVENTION
PRE-EXPOSURE PROPHYLAXIS (PrEP) In 2012, the FDA approved the first medication for the preven- tion of sexually transmitted HIV infection, the combination drug Truvada (emtricitabine/tenofovir DF) [60]. In 2019, another combination drug—Descovy (emtricitabine/tenofovir alafenamide)—was approved to prevent HIV infection [69]. In 2021, the FDA approved the first injectable agent for the prevention of HIV infection; cabotegravir (Apretude) is given first as two initiation injections administered one month apart, and then every two months thereafter [60]. In conjunction with safer sex practices, these agents have been found to be partially effective as PrEP in high-risk patients. The Chemoprophylaxis for HIV Prevention in Men study, also known as iPrEx, studied the effect of once-daily Truvada in 2,499 HIV-seronegative men or transgender women who have sex with men compared to placebo [61]. Researchers found that persons receiving Truvada experienced a 44% reduction in the incidence of HIV after a median of 1.2 years compared to placebo. Pre-exposure pro- phylaxis was most effective among participants at particularly high risk for HIV (i.e., self-reports of unprotected receptive anal intercourse). Research has indicated that Descovy and cabotegravir are similarly effective [69]. In 2021, the CDC updated their clinical practice guideline on PrEP used for the prevention of HIV infection [62]. Previ- ously, candidates for PrEP were primarily individuals at high risk for HIV (e.g., MSM, IDU). In the updated guidelines, the CDC recommends informing all sexually active and/or injecting drug using patients about PrEP, regardless of HIV risk factors. In addition, any patient requesting PrEP should be considered for treatment. These updates are intended to increase the number of patients who know about PrEP and prevent stigma or embarrassment that may prevent an indi- vidual from disclosing HIV risk factors [62]. Those identified as being at a substantially increased risk of acquiring HIV infection include sexually active individuals that have had anal or vaginal sexual contact in the past six months, in addition to having an HIV-positive sexual partner; a bacterial STI in the past six months; and/or a history of inconsistent or no condom use with sexual partners. Persons who inject drugs and have a HIV-positive injecting partner or share injection equipment are also at a high risk of HIV infection [62]. Patients should have a documented negative HIV test result within seven days prior to initiating treatment, and hepatitis B, kidney function, and a lipid profile should be reviewed to ensure appropriate PrEP selection.
Strength of Recommendation : AIII (Strong recommendation based on expert opinion)
53
MDCT2026
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