HIV Risk Behaviors Among Older American Drug Users

In recent years, researchers have voiced concern over the lack of attention given to illicit drug use among the elderly. The aging of the baby-boom generation, which has higher rates of substance abuse than previous generations, and longer average U.S. lifespans are leading to increases in the number of individuals older than 50 years of age. The numbers of older drug users are increasing, and several issues have been identified that differentiate them from their more frequently studied younger counterparts.

This situation is further complicated by the impact of HIV/AIDS on older individuals. Approximately 11 percent of all AIDS cases diagnosed through 1999 have occurred among adults 50 years or older, a figure that has been fairly consistent since the epidemic began. As with substance abuse, AIDS in older adults often is not diagnosed accurately, possibly because of the similarity of common AIDS symptoms to what is considered a normal part of aging or to the symptoms of other age-associated diseases such as Alzheimer's disease and depression. The importance of early diagnosis of HIV/AIDS is critical, given that studies indicate that older adults present for treatment at more advanced stages of the disease, progress more rapidly to AIDS, and have higher mortality rates compared with younger cohorts.

The purpose of the current study is to assess drug-related and sex-related HIV risk behaviors in a large national sample of intravenous drug users and crack smokers and to compare those who are older than 50 years of age with those who are 50 years or younger. The authors analyzed data from a National Institute on Drug Abuse cooperative agreement (CA) investigation of drug use and HIV risk conducted between 1992 and 1999. To date, 31,088 IDUs and crack smokers have been recruited and interviewed in 23 cities participating in the CA. Each participating site developed a targeted sampling plan in which local indicators of drug use were used to target neighborhoods with high concentrations of drug users. Study participants were recruited by community outreach workers, typically recovering drug users who were familiar with the local drug culture and the community. Outreach workers were responsible for locating potential subjects, explaining the study, and scheduling interview appointments.

Interviews were conducted using the Risk Behavior Assessment, a structured questionnaire developed by NIDA. The RBA includes questions regarding demographics, drug use, sexual behaviors, and health/medical history. Participants were compensated for their participation and offered free HIV testing and counseling. From the larger study sample, data from the 1,508 participants older than 50 years of age at the time of their initial interview were selected for analysis. To create a similar-sized comparison sample of younger drug users, a random sample of 1,515 drug users 50 years of age or younger was selected from the database using a random selection procedure. To better understand risk behaviors in the older cohort, three different comparisons were performed within the group older than 50 years of age: gender (male vs. female), crack (smokers vs. nonsmokers), and advanced age (51-59 years vs. 60 years or older).

Although older drug users older than 50 years were less likely to have had sex in the prior month, those who did were as risky as their younger counterparts with regard to sex-related behaviors. They were, however, significantly less risky in their needle sharing practices than those 50 years or younger. Among the older cohort, those who smoked crack were extremely risky. Men older than 50 years of age were riskier than women older than 50 years of age; however, users older than 60 years of age were no less risky than those in their 50s. One conclusion to be drawn from this research is that interventions aimed at reducing the transmission of HIV in older drug users and their sex partners should focus on sex risk behaviors. Street outreach, HIV testing and counseling, and the provision of condoms have been shown to be effective in reducing risk behaviors in general samples of drug users.

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