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HIV Prevention Strategies for Older Adults

By Judith A. Levy and Theodore Hufstader

Fall 2009

The popular belief that older persons rarely have sex or multiple partners has encouraged the belief that they are not vulnerable to HIV infection. Yet research shows that sexual behavior plays a significant role for most people throughout life and that many people in their 80s and 90s remain sexually active.


Introduction

People of any age who have unprotected sex are at risk for HIV. When compared with their younger counterparts, however, fewer older adults get tested for HIV or use condoms. They also are less likely to perceive themselves to be at risk for HIV or to take action to protect themselves. Many take no preventive action.

Like their younger counterparts, many older people use dating services and other methods to find partners. The internet has become an inexpensive and ready means to "hook up" or to search for lifelong companionship. Jane Fowler, founder of HIV Wisdom for Older Adults, reminds us through her own experience that newly single older adults often have little experience navigating the contemporary dating scene, including negotiating safer sex or starting conversations about condoms. Meanwhile, drugs like Viagra have enhanced the sex lives of many older and even younger couples. But unless safer sex is practiced, it could fuel increases in HIV transmission.

Recreational drugs pose a second risk factor for older adults. For many years, people who use drugs were thought to either die or "mature out of the life" by the time they reached their 50s. This assumption proved false when early HIV street outreach programs designed to prevent HIV among injecting drug users (IDUs) discovered unexpected numbers of older adults in the U.S. still shooting drugs. Most of these elderly IDUs began using heroin in their teens and early adulthood, followed by continuing careers of drug injection throughout their lives.

In contrast, late onset drug use is a relatively new drug behavior that has only recently been recognized as a source of HIV infection. In one of the few valid scientific studies of this trend, researchers at Emory University found that men and women who began using crack later in life differed by gender as to why they started drug use, number of sexual partners, and level of sexual activity. But both men and women had unprotected sex with high-risk partners.


Older Persons Are Not All the Same

Older men who have sex with men (MSM) face a unique set of challenges when it comes to HIV prevention. Having experienced stigma or discrimination at an earlier age, they now confront ageism as well as homophobia. Also, many gay men over 50 lost lovers and friends to the devastating effects of the AIDS epidemic in the 1980s and 90s. While some evidence suggests that this experience can enhance motivation to practice safer sex, current debates among gay men suggest that this norm may be changing due to such factors as "condom fatigue" and treatment optimism.

As they grow older, women who are sexually active also confront age-related factors that place them at special HIV risk. At menopause, decreased lubrication during sex and general thinning of the vaginal wall due to lower circulating estrogen can lead to abrasions and tearing during intercourse that facilitate entry of the virus. The woman and her partner also may be less likely to use a condom for contraceptive purposes once she is past childbearing age.

Among drug users, the social isolation that often characterizes their lives as older adults has important implications for both HIV risk and the use of AIDS-related services. Research by Levy and Anderson has shown that as they age, street drug users tend to shift from active participation in the general drug scene to covert drug use along its margins. Here they form a hidden population often relegated to performing the socially lowest work within the drug-trafficking world in order to obtain drugs. Often injecting drugs alone or with "running buddies" of the same age, fear of possible street violence from younger users or unintentionally coming to the attention of the police hampers their likelihood of seeking testing or accessing HIV services. Unfortunately, there appears to be little to nothing known about the HIV risk of more affluent older drug users or that of occasional recreational users.

The rate of new HIV infections from 2001 to 2005 in older adults was twelve times higher among blacks and five times as high among Latinos compared with whites.
Considerable racial disparity exists among older adults in terms of contracting HIV. Linley and colleagues found that the rate of new HIV infections from 2001 to 2005 in older adults was twelve times higher among blacks and five times as high among Latinos compared with whites. Older gay men of color are at triple jeopardy for HIV due to risks related to the stigmas of age, same-sex behavior, and race. Research conducted by David Jimenez in Chicago found that 37% of older gay men in his sample had not disclosed their same-sex behavior to friends, and 53% reported being "out" to less than half to none of their family members. CDC research shows that MSM of color are more likely to live outside of gay neighborhoods, beyond the reach of public health interventions directed at these areas. Minority older adults are also less likely in adulthood to have access to health care, if still working, or to qualify for Medicare, if retired.


HIV Screening and Diagnosis

Prevention Strategies for Older Adults People in their mid-70s and older grew up in a time when open discussion about sexual topics was considered inappropriate, and sexual norms differed considerably from those of today. This heritage of silence about sex can make it difficult for them to communicate with health care providers and others about HIV testing, prevention, or treatment. In contrast, those who came of age during the 1960s experienced a more permissive era. These youngest of older adults also have higher rates of drug use than previous generations. Nonetheless, research indicates that this age group seems just as reluctant to initiate discussions with health care providers or others about HIV.

Few physicians are taught to start conversations about sex with their patients or to recognize, diagnose, or treat HIV among older adults. As a result, they are less likely to test their patients over 50 for HIV. HIV disease can also mimic the normal conditions of aging, making it easy to miss the symptoms and signs that might be more readily recognized among younger adults.


Living With HIV as an Older Adult

Being older can have both positive and negatives effects on living with HIV. As is true of taking medication in general, older adults tend to demonstrate greater adherence to HIV treatment than their younger people. In a National Institute of Aging study, Karolynn Siegel found that older adults with HIV felt that having had more life experiences made it easier for them to cope with the challenges and the psychological stresses of living with the virus. Yet, these same older adults also felt that age made them less physically resilient, more socially isolated, less likely to evoke sympathy, and too accepting of lesser social service and medical care.

Older people tend to have less social support in coping with HIV. In general, people's social networks tend to shrink as they grow older, and many people over 50 live alone due to the death of a partner or spouse. Among older gay men, loss of network ties may partly reflect the death tolls of the epidemic. Studies also have shown that stress and depression due to HIV and other conditions can make if difficult to create and maintain supportive relationships. So adults may be less likely to have someone to call on for help when needed.


Interventions for Older Adults

Over 28 years have passed since the first AIDS case was reported in the U.S. While many successful programs and strategies have been developed for other high-risk populations, the needs of older adults have received little attention. Today's young people may receive HIV education in school, but HIV was unknown during the years that today's older adults were in the classroom. Low testing rates among people over 50 prevent the effectiveness of using these services as a point of contact for HIV counseling and referral. The stigma of high-risk behavior and a general reluctance to talk about risk factors hinder attempts to reach older adults about HIV prevention, treatment and care. So does the belief on the part of both older adults and others that people over 50 are not at risk.

Some organizations are beginning to focus attention on providing HIV services to older clients. The Latino Community Services in Hartford, Connecticut, recently launched Project REACH (Real Elders Achieving Community Health). Funded by a five-year grant from the Substance Abuse and Mental Health Services Administration, the program is designed to serve heterosexual older Latino men, ages 50 to 69, living in senior housing complexes. The project's main goals include working with substance abuse professionals, service providers, and key stakeholders to connect older adult Latino males to high quality substance abuse and HIV prevention services. In Detroit, Project S.H.A.P.E. at Adult Well-Being Services has been mobilized to address the needs of the older population in Southeast Michigan. In Chicago, Aging as We Are at Howard Brown Health Center aims to create a more comprehensive model of care for older gay, lesbian, bisexual, and transgender older adults.


Conclusion

Increased HIV prevention services to end transmission among adults of all ages are greatly needed as are special programs designed specifically for older adults. HIV education and training for service providers to improve prevention, diagnosis, and treatment for older adults also is vital. The number of older people with HIV is expected to increase dramatically -- by 2015, half of all people with HIV in the USA will be over 50. HIV-related medical and social services for this age group must be expanded if we are to ensure that these older Americans have the treatment and care they need to enjoy long and productive lives.

Judith Levy is Associate Professor of Health Policy and Administration at the University of Illinois at Chicago. Theodore Hufstader coordinates the Social and Behavioral Sciences Core of the Chicago Developmental Center for AIDS Research.

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