HIV Among Older Adults: Age-Specific Issues in Prevention and Treatment

Nathan L. Linsk, PhD

Disclosures

AIDS Read. 2000;10(7) 

In This Article

Older Adults and HIV Risk

Limited information exists regard-ing HIV knowledge and behavior among older adults. While older persons are at significant risk for HIV infection, they are almost universally omitted from prevention programs. Older adults have less HIV-related information than other at-risk populations. Almost all prevention messages are targeted to younger adults and, increasingly, to children and adolescents, neglecting older adults. At best, the illustrations and messages on prevention materials tend to be age-neutral, with images typically involving physically attractive younger persons.

The lack of targeted HIV prevention information reinforces the myth that older adults are not at risk for HI infection. The lack of information about HIV risk directed to older adults is compounded by the fact that HIV risk exists in a context of secrecy, especially in later life. Like younger men, older men may intentionally hide their sexual orientation, which promotes denial of sexual behavior. The same situation is true for extramarital sex, sex with commercial sex workers, and substance abuse in older adults. Denial may be so pervasive it affects the individual's belief system, yielding a sense that "I am not at risk" because "I am careful," "I engage in only certain sex practices," or "I am old."

Contrary to these assumptions, older adults may be at greater risk because of their age and the combination of denial and extreme secrecy. Risk may be intensified by an already compromised immune system related to age or other age-related health problems. Erectile changes may make condom use difficult, and vaginal changes may make women more vulnerable to viral infection.[4]Assumptions by older adults that they are safe because they are mo- nogamous, "nearly monogamous," know their partners, or do not engage in receptive anal sex may create false security.

Some research is available on HIV risk among older men who have sex with men. Slusher and colleagues[5] compared sexual behaviors among 432 self-identified homosexual men in Chicago ranging in age from 25 to 77 years. Comparison of men older and younger than 60 showed similar frequency of sexual contacts. While the younger men were at somewhat greater risk, the older men's HIV risk was, nevertheless, substantial. Forty-four percent of the older men reported multiple partners, closely matching the percentage (45%) in the 30 to 39 age group. Younger men, however, appeared to participate in a wider spectrum of sexual activities, including receptive anal intercourse. However, fewer of the older men were in a long-term relationship with another man. These investigators concluded that older gay men are often at risk for sexually transmitted diseases (STDs), that prevention education needs to be directed toward them, and that programs and policies need to address the needs of older as well as younger adults.

Kooperman[6] surveyed knowledge levels, attitudes, and behaviors among men in both heterosexual and homosexual samples. The survey results revealed fairly high levels of both HIV knowledge and sexual behavior among gay men, including substantial risky sexual behavior. Two thirds of 191 gay and bisexual men older than 50 in the United States, Canada, and Australia were "very concerned" about the HIV epidemic, but many were not able to apply their concerns to their own behaviors. Sixty-two percent reported they currently know or previously have known people with AIDS, and 19% reported knowing between 11 and 20 people with AIDS. Of the 139 persons who reported sexual behavior resulting in orgasm within 30 days before the survey, 121 (87%) reported they did not use condoms. While 32% felt sex (presumably, anal sex) is less enjoyable with condoms, the most reported reason (59%) was that they felt that "my partner and I are not at risk." Notably, 138 of the 191 respondents had been tested for HIV; of these, 132 reported negative tests, while the remaining 6 did not report their HIV antibody status. These findings suggest that although concern and knowledge about HIV may be high among older gay men, prevention behavior is inadequate, often relat- ed to the person's belief that he is not at risk. This indicates that information alone is not sufficient to achieve safe behavior and more complex interventions are needed.

Stall and Catania[7] examined results of the National AIDS Behavioral Surveys of 14,000 adults conducted in 1990-1991, focusing on risk of HIV infection among the US population. The sample included 4747 persons aged 50 or older. Forty percent of the 31 gay/bisexual men reported having at least 1 risk behavior for HIV infection, with multiple sex partners (23%) and a primary partner at risk (11%) being the most frequent risks. The larger sample indicates that overall among adults with at least 1 HIV-related risk behavior, more than 90% had not had an HIV antibody test, and more than 90% reported they never use condoms (83% of those in the high-risk city samples with at least 1 risk behavior never used condoms). However, in the small subsample of older gay men who were at risk (n = 12), only 9% never used condoms during sexual activity, while 52% reported always using condoms, and 60% had been tested for HIV antibodies. In this small sample of older gay/bisexual men, some had begun to practice HIV prevention activities.

Within the older adult age group, there has been even less research in other populations, particularly women and minorities, who represent groups increasing in number without adequate attention. Zablotsky[8] analyzed National Health Interview surveys and found that almost half (47%) of women older than 50 are totally uninformed about HIV, compared with only 14% among younger adults. Brown and Sankar[9] demonstrated that HIV is increasing among minority populations.

Primary care providers, geriatricians, and HIV specialists all need a strong knowledge base about HIV disease and its impact on older persons, both in terms of other health problems and with regard to social systems.

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