HIV and other sexually transmitted diseases are increasing in the over 50 population. In fact 10% of all new HIV infections in 2006 were to people over the age of 50. Protect yourself and your partners. Read and learn how to stay sexy and safe.
Author: Jill Shuman, MS, ELS
Following the death of her husband, at the age of 60, Grace was dating again. George, a close family friend she had known for a long time, was starting to stay overnight more and more often. Because she was past childbearing age, Grace didn’t think about using condoms. And because she had known George for so long, she didn’t think to ask him about his sexual history. So, Grace was shocked when she tested positive for HIV.
While Grace may have been shocked by her HIV-positive status, she squarely represents the epidemiologic shift in the incidence of HIV/AIDS over the past few years. According to the US Centers for Disease Control and Prevention (CDC), the annual estimated number of Americans older than age 50 and living with an HIV infection or AIDS increased more than 60% between 2003 and 2007.
Since the early 1980s, about 10% of all cases of HIV/AIDS nationwide occurred in those older than 50 — now, the percentage is closer to 30%. In 2006, new HIV infections in this population were responsible for 10% of all infections; what’s more, about half of the older people who test positive for HIV have been infected for less than 1 year (Box 1). In July 2010, the New York City Department of Health released a report confirming the CDC’s estimates: three-quarters of people with HIV/AIDS living in New York City are in their 40s or older, and more than one-third are older than 50.
Box 1. According to the CDC, adults ages 50 and older account for approximately—
· 10% of new HIV infections in the United States in 2006
· 21% of AIDS diagnoses in 2006 and 2007
· 28% of persons living with HIV/AIDS in 2007
· 34% of those living with AIDS in 2007, up from 24% in 2003
Adapted from ref 1
Why the Shift?
HIV among adults older than 50 is not a new phenomenon, particularly as the population ages and people are generally living longer. What has changed is the mode of transmission. In the early years of the HIV epidemic, blood transfusion was the major transmission mode among the senior population. Today, sexual contact is the most frequent cause of most new HIV cases in seniors — of all ages! According to a study published in 2007, 60% of men and 37% of women between the ages of 65 and 74 reported engaging in sexual intercourse at least a few times per month.
Changes in social norms now have transformed the way seniors live and love. Many older Americans have come out of lengthy marriages or relationships to re-enter the dating scene. Some meet up over the Internet without benefit of a formal introduction from a trusted companion or family member. Others are uneducated about HIV/AIDS or have old-fashioned views about the virus. A huge group of the "over-50" crowd never received sex education in school. Evidence suggests that women, who can expect to live an average of 5 years longer than men, are especially vulnerable to this information gap. In an analysis of National Health Interview data, researchers found that almost half of women older than 50 were totally uninformed about HIV, compared with only 14% of younger adults.
Safe Sex for All
While certainly enjoyable and healthy, certain aspects of sexual encounters in this population increase the potential of HIV infection. Many women older than 50 are less concerned with using barrier protections (condoms) because they are unlikely to get pregnant.
Older seniors may have less robust immune systems, making them more susceptible to infection. Older women are more likely to have thinning vaginal walls, which also increases their susceptibility to HIV. Some researchers suspect that the physical risk factors for HIV infection are compounded by the surge in drugs used to treat erectile dysfunction among older men, who often receive the drug without receiving any information about practicing "safe sex." These drugs probably do not cause an increase in the transmission of HIV; instead, their use may reflect a different sexual risk profile among users versus nonusers.
Research indicates that the most effective way to prevent HIV infection is to consistently use condoms, as they are nearly 90% effective against HIV transmission. However, many folks have yet to get the message, as recent studies suggest that sexually active heterosexual adults older than 50 are not consistently using condoms. Older adults are less likely than younger adults to use condoms because they are typically viewed as contraception.[6,7]
Condoms also may be difficult for some older folks to use. Arthritic hands or an incomplete erection may make it difficult to apply a condom, while poor lubrication may make condom use uncomfortable for some women.
In a survey conducted by University of Chicago researchers, nearly 60% of unmarried women between the ages of 58 and 93 said they didn't use a condom the last time they had sex. In an April 2009 survey conducted by AARP, 41% of seniors reported using a condom "rarely or not at all," while only 8% reported using a condom all the time. Even more disturbing, a study of almost 1000 adults in New York City found that among people older than 50 who knew they were HIV positive, about 27% of the men and 35% of the women reported having sex "sometimes" without using condoms.
Overcoming Barriers to Diagnosis and Treatment
For seniors, the stigma of HIV is a significant barrier to seeking information about prevention or treatment. Although support groups and teams are available in many communities, seniors may be unwilling to share their status with others. Older patients may also face ageism in general. They may be misdiagnosed by medical professionals and have limited access to HIV tests, information, and age-appropriate messages.
It can be extremely difficult to differentiate HIV-related illnesses from other age-related symptoms. For example, you might mistakenly assume that night sweats and depression are symptoms of menopause rather than HIV/AIDS. Other clinicians have diagnosed AIDS-related dementia or neuropathy incorrectly as early onset Alzheimer’s disease.
Many older Americans assume that they are immune to HIV/AIDS and are not told otherwise by their healthcare providers. In fact, studies indicate that 40% of primary care physicians do not assess HIV risk in persons older than 50. To combat the spread of HIV/AIDS among this population, the National Institute on Aging recommends that doctors and other healthcare professionals provide patients older than 50 with information on HIV transmission and at-risk behavior. In addition, medical providers should review a patient’s sexual and substance use history.
Subsequently, you should encourage voluntary HIV testing and provide risk reduction counseling, particularly since older individuals may mistake HIV symptoms for symptoms associated with aging. While the CDC has published guidelines for testing all patients for HIV, they only address the issue of testing until age 64. The lack of HIV testing among older Americans often results in an HIV diagnosis much later, at a point when the illness may have significantly progressed and treatment may be less helpful.
Like all Americans, individuals older than age 50 who are sexually active must hear the message that HIV/AIDS can affect them (Box 2). This message can be uncomfortable to deliver, but an understanding, accepting attitude, and a sensitivity to verbal and other cues help promote a more comfortable discussion of sexuality. Don’t assume that an older patient is heterosexual, no longer sexually active, or doesn’t care about sex. Depending on indications earlier in the interview, you may decide to approach the subject directly (for example, "Are you satisfied with your sex life?") or more obliquely with allusions to changes that sometimes occur in marriage or a changed social circumstance.
You can try to open the conversation by noting that patients sometimes have concerns about their sex life — and then wait for a response. Also effective is sharing anecdotes about a person in a similar situation or raising the issue in the context of physical findings (for example, "Some women find that sex with a condom is uncomfortable . . . have you experienced anything like that?").
Lack of communication about safe sex with all your patients perpetuates ignorance. You probably already talk to your younger patients about the importance of safe sex practices and sexual behaviors. While talking with older patients about sex may seem awkward or even disrespectful, it’s an important component of the medical visit (Box 3).
Box 2. Key Messages for Older Patients About Safe Sex
· Consider getting tested. The best way to protect yourself and your partner is to get tested for HIV before you start having sex.
· Know your partner’s sexual background before having sex. Talk about your sexual histories, acknowledge whether you’ve been tested for HIV and what the results were.
· Use a condom every time you have sex until you are in a monogamous relationship and know your partner’s sexual history and HIV status.
· Use a lubricant, as it can decrease the risk of tiny cuts on the penis or inside the vagina. These sores and cuts can boost risks of contracting HIV.
· Talk to your healthcare provider, who can offer additional advice about protecting yourself from the virus and can also recommend treatments for common sexual problems such as vaginal dryness and erectile dysfunction.
Box 3: Keep in Mind!
· Older adults continue to be sexually active; they also are less likely to use protection because pregnancy is not an issue post menopause.
· Older adults who are exposed to HIV are at greater risk than younger people because of weakened immune systems.
· Health providers may not screen older adults for sexually transmitted diseases because of lack of training or ageist attitudes.
· Older adults are not diagnosed properly as having HIV/AIDS because many of the symptoms resemble the symptoms of old age.
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