July 21, 2003
In the United States, AIDS is most prevalent among men who have sex with men, but few studies have examined HIV prevalence and risk behavior among older MSM (50 years or older). Moreover, earlier studies based on representative samples are of unknown generalizability beyond high-density "gay neighborhoods," and opportunistic samples are biased in terms of overrepresenting MSM with high levels of risk or HIV cofactors. There is a need for unbiased estimates of HIV prevalence and sexual practices of older MSM.
By developing methodologic procedures to achieve this goal, the Urban Men's Health Study was able to obtain a probability sample of MSM in multiple cities that includes representation of MSM outside high-density gay neighborhoods and in the older age ranges (50-85 years old). The authors conducted a telephone survey of MSM from four urban centers -- San Francisco, Los Angeles, New York, and Chicago -- where the proportion of households with telephones is approximately 95 percent.
The authors conducted pre-survey community awareness programs in each city. Households were screened by telephone interview to determine initial eligibility; subsequent eligibility was based on sexual orientation of adult male residents. The authors screened more than 95,000 households on geographic location and household gender makeup. Approximately 55,000 households were eligible based on geographic and gender criteria. Approximately 13.3 percent of households with an adult male member in the combined sampling areas contained 1 or more MSM. The authors obtained 2,881 completed interviews from November 1996 through February 1998 (78 percent of all identified MSM households; n=3,700). Approximately 17 percent (n=507) of the respondents were 50 years or older. HIV prevalence data were computed based on combined data from self-reports and biologic testing.
The present study characterized the HIV epidemic among older MSM residing in large urban centers in the late 1990s. The data suggest that the HIV epidemic among older MSM (50 years and older) is at a very high level (13 percent). The highest prevalence rates were found among men in their 50s (19 percent) and 3 percent for men in their 60s. No men in their 70s were HIV-positive. Risk behavior is relatively stable until the age of 70, at which point decreases are observed. HIV prevalence rates for older urban MSM were only slightly lower than for the overall urban MSM population and are on a par with the prevalence levels in sub-Saharan Africa.
The authors found extremely high HIV rates among older blacks (30 percent), although ethnic differences did not reach significance in this sample due to sample size limitations. HIV rates varied significantly by closetedness, sexual orientation, and non-IDU substance use. Significantly higher HIV prevalence levels were found for less closeted men (21 percent), more gay-identified men (15 percent), and moderate substance users (35 percent) than for their respective counterparts.
These findings suggest that older MSM in their 50s and 60s continue to have active sexual lives and engage in behaviors that pose risk. This study provides strong evidence of the need for behavioral intervention in this segment of the population. Formative work is needed to determine what approaches best address the needs of sexually active older urban MSM. Also this study suggests that this population is an important segment to conduct HIV surveillance and prevention work.
Journal of Acquired Immune Deficiency Syndromes
06.01.03; Vol. 33; Suppl. 2: P. S115-S121, M. Margaret Dolcini; Joseph A. Catania; Ronald D. Stall; Lance Pollack