High-Risk Older Patients Are Not Screened for HIV

Jill Stein

May 31, 2011 (National Harbor, Maryland) — Older high-risk patients rarely undergo HIV testing when they present for the first time at an outpatient primary care clinic, investigators reported here at the American Geriatrics Society 2011 Annual Scientific Meeting.

Researchers at Wayne State University School of Medicine, in Detroit, Michigan, reviewed the electronic records of 350 patients 65 years of age and older who had their first appointment at an ambulatory geriatric clinic during a recent 12-month period.

The results showed that the rate of HIV testing was only 5.02%, and that the presence of HIV risk factors had almost no effect on whether HIV testing was conducted or not.

"Ideally, new patients undergo screening for sexually transmitted diseases at their index visit," principal investigator Aaron Kirsch, a third-year medical student," told Medscape Medical News.

"We were disappointed to find such a low rate of HIV testing in our high-risk study population, given that the Centers for Disease Control and Prevention recommends annual HIV testing for all high-risk individuals," he said. "We were especially disappointed to learn that, except for a history of erectile dysfunction [ED] or a history of treatment for erectile dysfunction, the presence of well-known HIV risk factors did not motivate clinicians to test a patient for HIV infection at his or her first visit."

With changing demographics, most HIV patients will soon be 50 years of age or older, Mr. Kirsch noted. Age has been shown to accelerate the progression of HIV to AIDS, he added.

Low Rate of HIV Testing

Mr. Aaron Kirsch

For the study, the researchers obtained information about marital status, number of sexual partners, ED or medications for ED, intravenous (IV) drug use, same-sex sexual relations, history of sexually transmitted infection, Charlson Comorbidity Index (CCI) score, and the number of medications prescribed as a marker for comorbidity.

Study patients had a mean age of 77.3 years, 68% were women, and 78.4% were African American. Their median CCI score was 2, and they were taking an average of 7.6 medications.

Only 18 patients (5.02%) were tested for HIV infection.

Factors predictive of HIV testing were a history of ED or being prescribed an ED medication (χ², 15.19; P = .000).

Patients were "almost never" asked about HIV risk factors, Mr. Kirsch said. "We are not asking the questions that should ordinarily be asked when a patient history is obtained at the initial visit."

The analysis revealed that provider characteristics did not affect screening. "It didn't matter if the provider was a geriatrician or nurse practitioner or male or female," Mr. Kirsch said. "There was huge oversight among all clinicians."

"Older patients, particularly if they are having sexual relations and/or using IV drugs, still have risk factors and need to be tested for HIV infection," Mr. Kirsch explained. "Older patients have a weaker immune system than younger patients; thus, older patients are more vulnerable to the effects of HIV."

A Major Clinical Challenge

HIV infection is definitely "a growing problem" in the elderly, and this study, regrettably, adds to the growing literature documenting the low rate of HIV screening in older patients, said Amy R. Ehrlich, MD, interim chief of the division of geriatrics and geriatrics fellowship program director at Montefiore Medical Center and Albert Einstein College of Medicine in Bronx, New York, in an interview with Medscape Medical News.

"HIV infection has been the purview of infectious disease practitioners and HIV specialists over the past 20 years, and geriatricians and [primary care physicians] taking care of older adults have simply not been screening older patients for HIV infection," she said. We are going to have to alter our thinking and devise a new treatment approach because the HIV team will need geriatricians and other physicians to help take care of older adults who have multiple medical comorbidities. How we are going to manage these patents is going to become one of the major healthcare issues in the coming years."

She cited 2 reasons for the increase in older adults with HIV infection. "First, people are living longer with the disease," she said. "Second, there are new cases of people who are sexually active who are still contracting HIV disease."

More important, HIV infection in an older patient is often not detected until the patient has flagrant disease and is hospitalized, because "we don't have it in the differential."

Finally, Dr. Ehrlich emphasized that physicians need to ask their older patients about sexual activity and to explain the importance of safe sex. "Older patients may be sexually active. Historically, your patients are older than you and may feel uncomfortable talking about sexual issues. Studies have uniformly shown that physicians don't routinely ask their patients about safe sex. It's something that needs to be incorporated into routine primary care."

The study received no outside funding. Mr. Kirsch and Dr. Ehrlich have disclosed no relevant financial relationships.

American Geriatrics Society (AGS) 2011 Annual Scientific Meeting: Abstract A124. Presented May 12, 2011.