Take Home points
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The U.S. Preventive Services Task Force (USPSTF) strongly advises physicians to screen all adults at high risk for human immunodeficiency
virus (HIV). This recommendation is one of several primary clinical recommendations recently released from the USPSTF.
"While the message about high-risk applies to a patient of any age, it's not likely that there are [many] people over age
60 who have newly acquired HIV infections," Diana Petitti, MD, USPSTF vice chair, said in an interview with GERIATRICS.
Nevertheless, the number of older adults (over age 50) with HIV appears to be growing steadily. Experts attribute this primarily
to the fact that those diagnosed with HIV within the last 15 years are living longer and into their senior years. This month,
GERIATRICS' cover article, which features a case report and literature review of HIV and AIDS, cites one reference that found
that more than 10% of HIV infection is found in adults age 50 and older. However, the article went on to say that rates of
HIV infection among older adults are not easy to confirm, since few adults age 50-plus are routinely tested for HIV.
Therefore, Dr. Petitti said the message to physicians and the patients they treat is that: "anyone who engages in high-risk
behaviors is at risk of HIV."
Such "high-risk" behaviors, according to the guidelines, include:
- men who have had sex with men after 1975
- men and women having unprotected sex with multiple partners
- past or present injection drug users
- persons being treated for sexually transmitted diseases; and
- persons with a history of blood transfusion between 1978 and 1985.
Those who ask for testing without reporting any risk factors may also be considered at higher risk, since, according to USPSTF,
this group may not be willing to disclose high-risk behaviors.
A person is considered "high-risk" for HIV (and should be offered testing with informed consent) if he or she reports at least
one risk factor or receives health care in a high-prevalence area.
The guidelines are an update of 1996 recommendations, in which USPSTF advised routine counseling and screening for all persons
at increased risk for HIV infection. The update also includes a "non-recommendation," advising neither for nor against routinely
screening for HIV adults who are not at increased risk for HIV infection.
There's a possibility that HIV may still be below the radar in older adults because of lack of screening on behalf of clinicians,
according to Dr. Petitti, senior science adviser for Kaiser Permanente. But there may be solid reasons behind such lack of
screening. "Primary care physicians are quite reluctant to raise the issue with their patients. Many physicians in general
think they know their patients and they make certain assumptions about them based on their knowledge of them rather than asking
the question (eg, "Did you engage in any of these high-risk behaviors?") before proceeding to screen them," said Dr. Petitti.
She said the issue of screening boils down to a physician's ability to ask the uncomfortable questions. "Many people, physicians
included, have a hard time asking questions about other peoples' sexuality and sexual life. There's not as much training on
the kind of interview techniques that one can use to reduce a patient's and one's own anxiety."
Since training may be lacking in this area, Dr. Petitti recommends that physicians devise a standardized approach to all patients.
She says that one could preface a question with, "I ask all of my patients ... do you have multiple sex partners (for example)?"
A questionnaire may be another "safe" approach.
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