How many times have you seen a billboard with the message that older adults may be at risk for HIV? How many times have you heard of an HIV testing campaign targeting your grandmother? How many programs do you know of that teach your father how to practice his condom skills? From the amount of attention it gets, you'd never think that older adults are at risk for HIV or sexually transmitted diseases (STDs). Many people don't want to imagine their parents and grandparents, uncles and aunts engaging in any behavior that might place them at risk for HIV.
Even service providers with patients who might look like their older relatives have difficulty asking questions related to sexual or substance use history, or to offer an HIV test, much less any HIV risk education. Doctors are not immune to the ageist stereotypes of our society, and this can be a problem both in prevention and diagnosis of HIV in seniors. The doctor who does not see past the silver hair may not ask older patients about their sexual activity or drug use and may not give the prevention information that is routine for younger patients. Age is not a barrier to HIV -- we are all at risk.
The risk factors for infection are the same regardless of age: unprotected sex or sharing needles. We tend not to think of older people as being sexually active or using drugs, but a Columbia University study showed that 45% of people over 50 reported risk factors, including multiple partners, STDs, and alcohol or drug use.
HIV has become a significant national problem among older adults. The rates of infection in this group continue to increase, with 28% of people with HIV in 2006 being over 45, compared with 22% in 2001. According to the CDC, in 2009 this group accounted for 29% of all new HIV diagnoses. The CDC estimates that by 2015, half of all people with HIV in the U.S. will be over 50, and that more than a third will be women. The longer survival of people diagnosed earlier in life also accounts for much of the increasing number of older adults with HIV.
Contrary to stereotypical beliefs, older adults long for active, satisfying sex lives. The fact that sexual contact is the most common HIV transmission route among older adults confirms the presence of both sexual activity and sexual risk behaviors among this population. Results from national surveys examining the sexual activity among persons over the age of 60 indicate that more than 92% consider sex an important part of life and that 75% of those between 65 and 74 considered themselves sexually active. Although little is known about the sexual behaviors of older adults with HIV, new data suggest that sexually active older adults are engaging in risky sexual behaviors.
Although risk-reduction interventions tailored for the needs of people with HIV have begun to demonstrate promising results, only a few have focused on HIV-positive older adults. They include:
- ACRIA's Community PROMISE program -- targeting older HIV-positive men who have sex with men or who are at risk for HIV, older women of color with HIV or at risk for it, and older adults who don't see themselves at risk for HIV or STDs.
- Latino Family Services, Hartford -- targeting older Latino men with substance use and mental health issues. The organization has created a curriculum called "Healthy Men, Healthy Lives" as part of a five-session program that targets Latino men over 50. One of the sessions is dedicated exclusively to HIV and uses several tools, among them ACRIA's own "Older and Wiser" DVD and discussion manual.
- Adults Well-Being Services, Detroit -- targeting older African-American HIV-positive men and women with substance use and mental health issues.
- Project ROADMAP (Reeducating Older Adults in Maintaining AIDS Prevention), Miami -- an intervention designed to reduce high-risk sexual behaviors among older people with HIV in primary care clinics.
- Brothers to Brothers/Sisters to Sisters, Wright State University, Ohio -- adapting Community PROMISE to target older African-Americans.
Although the CDC funds HIV interventions that use its Diffusion of Effective Behavioral Interventions (DEBI) program, none of the funded organizations target older adults. Perhaps there is a belief that HIV prevention is the same for everyone. There has long been a need to tailor approaches to target specific groups. Why hasn't the CDC made any attempt to fund a program that creates an HIV intervention for older adults?
Old and Young
Research has found differences between older adults and their younger counterparts in terms of sexual knowledge, risk behaviors, and biological factors, showing the need for age-appropriate interventions. Older age has been linked with having incorrect information about prevention, including the need to protect oneself during high-risk behaviors. In contrast with younger people, many older adults do not consider unprotected sex a high-risk behavior because many are no longer concerned about birth control, making them less likely to use condoms. Studies suggest that older adults' knowledge of the seriousness of HIV may not affect their perceived threat of AIDS or their use of condoms.
Multiple health problems and age-related physical changes may make older adults particularly vulnerable to HIV. For example, postmenopausal women are at greater risk for HIV because of the fragility of the vaginal mucosa, due to decreased levels of estrogen. In addition, older patients may progress more quickly from HIV to AIDS. Furthermore, there is often a delay in diagnosis due to clinicians underestimating the risk for HIV among older adults and common HIV symptoms being mistaken for signs of aging. More importantly, older adults may not seek testing because they do not believe themselves to be at risk. Thus, cultural, biological, and behavioral vulnerabilities may make efforts to target high-risk sexual behaviors even more critical in the older population.
- Many older persons are sexually active but are not practicing safer sex.
- Older women are especially at risk because age-related vaginal thinning and dryness can cause tears during intercourse.
- Some older persons inject drugs or smoke crack cocaine, which puts them at risk for HIV. HIV transmission through injection drug use accounts for more than 16% of AIDS cases in people over 50.
- Some older persons may be less knowledgeable about HIV than younger people, may not perceive themselves as at risk, not use condoms, and not get tested for HIV. Older persons of color may face discrimination and stigma that can lead to reluctance to seek services, and delayed testing and diagnosis. HIV stigma may be more severe among older persons, leading them to hide their diagnosis from family and friends. This can limit the emotional and practical support they receive.
- Ageist assumptions have been challenged by several decades of research, which has generated a set of principles:
- It is never too late to introduce healthy behavior.
- There is a need for social and behavioral interventions across the entire lifespan, especially in light of the cumulative impact of risk factors on vulnerable populations.
- Older adults can be recruited into health intervention studies if we address the unique barriers they face.
- Today's interventions should place an emphasis on maintaining quality of life and reducing age-related conditions.
- We should move toward "functional age" and away from "chronological age," because the former is less likely to fall into stereotypes such as "older people don't have sex and don't use drugs."
- Health care professionals may underestimate older patients' risk for HIV and miss opportunities to deliver prevention messages, offer HIV testing, or make early diagnoses that could help their patients get needed care.
Social marketing campaigns targeting older adults are necessary to encourage safer sex. As people get older, women increasingly outnumber men. When there are many more women than men, women have less power, putting them at a disadvantage when negotiating condom use. Campaigns promoting condom use and the female condom could provide important prevention tools.
Many sexually active older adults take part in high-risk activities but are unaware of the need to protect themselves. ACRIA's Research on Older Adults with HIV (ROAH) study looked at older adults with HIV in New York City. Of those who were sexually active, 47% used drugs or alcohol before sex. Another study found that 60% of older single women have had unprotected sex within the past decade. The CDC reports that over half of older African-American women living in rural areas have at least one risk factor for HIV.
A study in England found that STD rates more than doubled among older adults in less than a decade. While experts attribute the rise to trends such as a high divorce rate and online dating, many highlighted the lack of sexual knowledge among older adults as the principal reason for the increase. The study recommended that "safe sex messages and sexual health research should target all sexually active members of the population, including older people." Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases stated, "While it's a good thing that older people are more sexually active, they need to connect the dots, see they're at increased risk, and make sure they use condoms."
The CDC recommends routine HIV screening for persons up to age 64. Persons over 64 should be counseled to receive HIV testing if they have risk factors. Routine testing is intended not only to identify persons who are unaware that they are HIV infected but also to remove the stigma of being tested. Making testing routine for older persons can open a discussion about risk behavior.
Prevention strategies should be developed for older persons who are at risk: education to increase awareness, skills training to help negotiate risk reduction, and messages that are age-appropriate and culturally sensitive. Intervention strategies to help older women negotiate safer sex are especially important.
A recent review of HIV behavioral interventions for people over 50 recommended simultaneous approaches, including building on our current understanding of behavior change and HIV prevention successes with younger people while considering important lessons learned from work with older adults in other health areas. Given the complexity of the problem, our solution must be comprehensive, learning from and intervening with individuals, families, health care professionals, communities, and society as a whole.
We must take into account the special needs of older adults and involve a variety of groups who have not traditionally been associated with HIV prevention efforts. Strategies for extending successful interventions to the entire over-50 population need development and evaluation.
Luis Scaccabarrozzi is Director of the HIV Health Literacy Program at ACRIA.