Sexuality is an integral part of human identity. A healthy sex life may include relationships that evolve into friendships and sometimes lifelong commitments. And it can contribute to happiness, confidence, and pride. Yet persistent stigmas surrounding aging and HIV often limit the opportunities for sexual expression among older adults, especially those with HIV. When combined with other stigmas, such as homophobia, transphobia, or racism, it's a wonder that many ever get out of their beds, much less into someone else's!
Persistent ignorance and prejudice contribute to many older adults with HIV being afraid to speak openly about their sexuality with their physicians and services providers, who too often, perhaps unwittingly, exhibit biases of their own. For an older adult with HIV who wishes to enjoy a full life that includes a healthy sex life, persistent and pervasive stigmas can lead to social isolation, depression, and selfesteem issues. And they can create other challenges like failing to practice safer sex consistently.
People with HIV of every age face tremendous disclosure challenges in sexual relationships. Widespread myths that fuel HIV stigma lead some to conclude that people with HIV are a public health danger and shouldn't be having sex at all. Facts relating to safer sex, treatment that leads to undetectable viral loads, and other prevention methods are ignored. Worse, where HIV is criminalized, people with HIV are effectively banned from having sex if they aren't prepared to disclose, no matter their sexual behavior or the level of risk, and are frequently prosecuted even when they do.
Notwithstanding the challenges and pervasive myths (including that older adults are either monogamous or asexual), there is substantial evidence that many people remain sexually active well past age 50, and often with multiple partners. And, like others, older adults have unprotected sex. But unlike virtually all other at-risk populations, there are very few HIV or STI prevention interventions targeted to those who are in middle age or beyond. For a host of reasons, many older adults have drastically different experiences with and perceptions about HIV than their younger counterparts, including the belief that they are less at-risk than others.
What to do? Here's a short and smart advocacy and policy agenda for leaders in the U.S. and around the world:
- Testing: Make HIV testing of adults routine without regard to age. It is time to modify the CDC's recommendation, which presently ends routine testing at age 64. It is both cost effective and sensible public health policy to test all adults routinely. This change alone could encourage more providers, and older adults themselves, to initiate useful and instructive discussions about their sex lives and, as a result, conversations about HIV and STI prevention.
- Research: Fund targeted research, particularly among older men who have sex with men (MSM ). Although one in six new HIV diagnoses in the U.S. is among older adults (a rate that is steadily increasing), there is a gross lack of data and information about older adult sexuality, particularly that of older LGBT adults. We very much need this information to more effectively design strategies that target HIV and ST I prevention for older adults, especially older MSMs.
- Training: We can't lessen, much less eliminate, the impact of HIV stigma and ageism if we don't educate providers -- from physicians and nurses to social workers and case managers -- on the scourge of multiple stigmas. And we can't hope to end this epidemic if those most at risk won't approach providers and remain engaged in services because they feel unseen, unwelcome, or misunderstood. It is well past time to stop behaving as though older adults aren't having sex. Funding training for all health providers on how best to initiate conversations about the sex lives of their older adult patients, especially MSM s, without reinforcing silence and stigmas is vital. And cultural competency training at the intersection of HIV, ageism, homophobia, transphobia, racism, and sexism can make a genuine difference in the quality of the services they deliver.
- Education: Of course, the corollary to training for health providers is targeted educational materials for older adults themselves, including funding for widespread and engaging social messaging campaigns on HIV and ST Is that include prevention messages.
Aging is challenging -- as is living with HIV -- but it doesn't have to be. A coalition of advocates, public health agencies, and service providers must work to ensure that older adults, regardless of their HIV status, are able to age gracefully, soundly, and healthily. And that includes having exciting and healthy sex lives!