HIV/AIDS does not spare older people.

A common perception is that AIDS afflicts only young people. In HIV/AIDS prevention campaigns, wrinkled faces are seldom featured. Global reporting of HIV/AIDS prevalence tends to refer only to children and individuals of reproductive age (ages 15 to 49 years), as if persons 50 years and older could not be infected with HIV or develop AIDS. (1) Many older people themselves believe their risk of HIV infection is low. (2) Often unfamiliar with methods to prevent sexually transmitted infections (STIs), including HIV, and no longer needing contraception, they are unlikely to use condoms consistently during sex for either pregnancy or disease prevention. (3)

Furthermore, believing themselves to be at low risk of HIV/AIDS, many older people do not seek testing for HIV infection. (4) If they become sick with AIDS, they may dismiss their symptoms as part of the aging process. Not receiving or delaying diagnosis and treatment of AIDS decreases the likelihood of survival. In fact, older people often do not survive as long as younger people because of delays in diagnosis and treatment (5) and because age appears to accelerate the progress of HIV infection to AIDS. (6)

Despite the impression that AIDS is a younger person's disease, older people are not spared. Older, sexually active men and women at risk of infection should adopt safe sexual behaviors, such as using condoms correctly and consistently.

In the United States, about 11 percent of AIDS cases occur among people ages 50 years and older, with that number reaching 15 percent in some parts of the country. Heterosexual sex is increasingly a source of these infections. (7) Trends are similar in other developed countries. In Western Europe, about 10 percent of new HIV infections reported between January 1997 and June 2000 were among people older than 50 years. (8)

"The share of total AIDS cases among people ages 50 years and older in developing countries is generally lower than that in developed countries, probably because there are relatively fewer older people in these populations," notes Dr. John Knodel, a professor at the University of Michigan's Population Studies Center and principal author of a recent report about the global impact of AIDS on persons 50 years or older. (9) "The percentages of cases occurring in men or women ages 50 years or older are approximately 5 percent in Asia, 6 percent in Africa, and 7 percent in Latin America. In Africa and Asia, where heterosexual intercourse is the main mode of HIV transmission, older men tend to have higher rates of HIV infection than older women. This likely reflects the fact that sexual relations typically occur between couples in which the man is older than the woman." (See chart page 27.)

In view of these statistics, reproductive health care providers should keep in mind that:

* Many older people are sexually active. A 1999 survey by the U.S.-based American Association of Retired Persons (AARP) of a nationally representative sample of 1,384 people 45 years and older found that approximately two-thirds of men and women ages 45 to 59 years who had sexual partners said they had sexual intercourse at least once a week. (Over a quarter of those 75 years and older reported doing so.) (10) And a study of sexual activity among persons ages 50 years and older in Thailand, based on a large nationally representative survey conducted in 1995, found that substantial proportions of older married Thais remain sexually active, although at lower levels than older persons in Western countries. (11) (See graph, page 28.)

* If older clients are sexually active, they may be at risk for HIV. Many persons diagnosed with AIDS at 50 years or older were probably infected as younger adults, but many infections are newly acquired--often through heterosexual sex. (Specific risks associated with heterosexual sex include unprotected sex, multiple sexual partners, and infection with other STIs.) That older persons often face these risks was demonstrated in a six-year, retrospective study of 239 new patients, 60 years and older, receiving genitourinary medical care at a hospital in the United Kingdom. Over half (121) of the 239 patients were single, divorced, separated, or widow/widowers. They were "on their own," the researchers noted, "resulting in sex with casual partners and even with prostitutes. On the other hand, protective sex was performed by only a minority of this group, probably because they link protection with contraception only." (12)

* Discussing sexuality or asking questions about sexual activity may be appropriate with aging clients. Older people are less likely than younger people to talk about such matters with a doctor, and doctors tend not to ask their older patients about sexual behavior. (13)

* Providers should be prepared to discuss HIV/AIDS, its risk factors, and safe sex practices with older people. Older people, in both developed and developing world settings, often know less than younger people about HIV/AIDS. (14)

* Counseling older, sexually active, at-risk clients to use condoms is important. A 1994 U.S. study, based on data from two large cross-sectional national surveys, found that at-risk persons 50 years or older were one-sixth as likely to use condoms during sex as at-risk persons in their 20s. (15) Another U.S. study conducted in 12 state and local health department clinics among 556 women with AIDS attributed to heterosexual contact (11 percent of whom were 50 years or older) showed that older women were less likely than younger women to have used a condom before their HIV diagnosis. (16)

* Physical changes associated with menopause (such as a decrease in vaginal lubrication, vaginal shortening and narrowing, and thinning of vaginal walls) can increase a woman's risk of STI/HIV infection if she has unprotected sexual intercourse.

* Suggesting that an older, at-risk client be tested for HIV infection, particularly if that person reports feeling sick, may be appropriate. A study in New York City among 78 HIV-infected men and women ages 50 years and older indicated that asymptomatic individuals often waited to get HIV testing or medical care, even if they knew they were at risk for the infection. Even those with symptoms often delayed seeking HIV testing or medical care, attributing those symptoms to other illnesses, normal aging, or menopause. (17)

Meanwhile, many health care providers are not well aware of older persons' risk for HIV infection (18) and may be less likely to suspect it among older clients than among younger ones. About two-thirds of 330 U.S. primary-care physicians surveyed in 1996 reported that they rarely or never discussed HIV/AIDS or HIV infection risk reduction with patients older than 50 years. They were also less likely to counsel older patients to seek HIV testing than younger patients. (19) This failure to consider the possibility of HIV infection among older persons is due in part to the fact that AIDS-related opportunistic infections that commonly occur among persons ages 50 years or older (HIV encephalopathy and wasting syndrome) often have symptoms similar to those of other diseases associated with aging (Alzheimer's disease, depression, and cancer). (20) These symptoms include memory problems, fatigue, and weight loss. Health professionals also may make the mistake of assuming that night sweats and depression are only symptoms of menopause, when they may be symptoms of AIDS. Such confusion often results in older people with AIDS not having their disease diagnosed. (21)

* Postponing testing and treatment increases the chance that HIV-infected people will transmit the virus and may result in life-threatening delays in treatment, if available. The length of time between HIV infection and the development of AIDS--as well as total survival time--is shorter among HIV-infected older people. (22) As of 1996 in the United States, persons 50 years and older with AIDS were twice as likely as younger persons to die within a month of their diagnoses. (23) In a 1998 U.S. study of 321 AIDS patients ages 60 years and older and 7,511 AIDS patients 20 to 39 years old, older patients' median life span from time of diagnosis was nine months compared to 22 months for younger patients. (24)

* Even when antiretroviral drugs are available, an older person with HIV/AIDS is more difficult to treat than a younger person. Older individuals are more likely than the young to have chronic medical problems--such as high blood pressure, diabetes, peripheral vascular disease, and coronary artery disease--and the drugs they take for these conditions may adversely interact with drugs used to control HIV/AIDS. However, a recent U.S. study among 101 patients ages 50 and older and 202 patients ages 18 to 39 years, all of whom received antiretroviral therapy from 1993 through 1999, found that older patients were more likely than younger patients to achieve blood levels of HIV below detectable limits, perhaps because they were less likely to stop taking their medications. (25)

OLDER PERSONS AS PERCENTAGES OF AIDS CASES

                                      PERCENTAGES OF CASES AGES
                                            50+ YEARS

                       TOTAL AIDS
   COUNTRY               CASES       TOTAL    MEN     WOMEN

Africa (1)              233,336       5.6      7.3     3.6
Asia (2)                119,320       4.5      4.8     2.9
Latin America (3)       198,322       7.4      7.6     7.0
Other
   Australia              8,096       9.3     12.4    17.0
   Canada                16,235      11.2     11.0    16.3
   France                49,421      12.9     13.1    12.4
   Germany               18,515      16.4     17.2    10.4
   United Kingdom        16,791      11.0     11.7     5.6
   United States        733,371      10.7     11.0     9.1

Source: U.S. Centers for Disease Control and Prevention. UNAIDS
epidemiological fact sheets for individual countries, 2000 update.
HIV/AIDS Surveillance Rep 1999;11(2). In Knodel J, Watkins S,
VanLandringham M. AIDS and Older Persons: An International
Perspective, PSC Research Report 02-495. Ann Arbor, MI: Population
Studies Center, 2002.

(1.) Based on data for 26 countries; 65% of the cases attributable to
Cote d'Ivoire and Tanzania.

(2.) Based on data for 10 countries; 96% of the cases attributable to
Thailand.

(3.) Based on data for 7 countries; 91% of the cases attributable to
Brazil and Mexico.

REFERENCES

(1.) Joint United Nations Programme on HIV/AI DS. Report on the Global HIV/AIDS Epidemic, June 2000. Geneva: UNAIDS, 2000; Joint United Nations Programme on HIV/AIDS, World Health Organization. AIDS Epidemic Update: December 2000. Geneva: UNAIDS and WHO, 2000.

(2.) Rose MA. Knowledge of human immunodefidency virus and acquired immunodeficiency syndrome, perception of risk, and behaviors among older adults. Holist Nurs Pract 1995;10(1);10-17.

(3.) Gordon SM, Thompson S. The changing epidemiology of HIV in older persons. J Am Geriatr Soc 1995;43(1):7-9.

(4.) National Institute on Aging. AgePage. HIV, AIDS, and Older People. 1999. Available: http://www.nia.nih.gov/health/agepages/aids.htm; U.S. Centers for Disease Control and Prevention. AIDS among persons aged 50 [greater than or equal to] years. United States, 1991-1996. MMWR 1998;47(2):21-27. Also available: http://www.cdc. gov/mmwr/preview/mmwrhtml/00050806.htm.

(5.) U.S. Centers for Disease Control and Prevention.

(6.) Skiest DJ, Rubinstein E, Carley N, et al. The importance of comorbidity in HIV-infected patients over 55: a retrospective case-control study. Am J Med 1996;101(6):605-11; Adler WH, Baskar PV, Chrest FJ, et al. HIV infection and aging: mechanisms to explain the accelerated rate of progression in the older patient. Mech Ageing Dev 1997;96(1-3):137-55; Phillips AN, Lee CA, Elford J, et al. More rapid progression to AIDS in older HIV-infected people: the role of CD4 T-cell counts. J Acquir Immun Deficien Syndr 1991;4(10):970-75.

(7.) U.S. Centers for Disease Control and Prevention.

(8.) Joint United Nations Programme on HIV/AIDS. Impact of HIV/AIDS on Older Populations. Geneva: UNAIDS, 2002. Available: http://www.unaids.org/fact_sheets/files/FSolder_en. html.

(9.) Knodel J, Watkins S, VanLandingham M. AIDS and Older Persons: An International Perspective. PSC Research Report No. 02-495. Ann Arbor, MI: Population Studies Center, 2002.

(10.) American Association of Retired Persons. Modern Maturity Sexuality Survey: Summary of Findings. Washington: AARP, 1999. Available: http://www.research.aarp.org/health/ mmsexsurvey_l.html.

(11.) Knodel J, Chayovan N. Sexual activity among the older population in Thailand: evidence from a nationally representative survey. J Cross-Cult Gerontol 2000;16(2):173-200.

(12.) Jaleel H, Allan PS, Wade AA. Sexually transmitted infections in elderly people. Sex Transm Infect 1999;75(6):449.

(13.) LeBlanc AJ. Examining HIV-related knowledge among adults in the U.S. J Health Soc Behav 1993;34(March):23-36; National Institute on Aging.

(14.) National Institute on Aging; Im-em Wassana, VanLandingham M, Knodel J, et al. Knowledge and Attitudes of Older People about HIV/AIDS in Thailand: A Comparison with Young Adults. PSC Research Report No. 01-464. Ann Arbor, MI: Population Studies Center, 2000.

(15.) Stall R, Catania J. AIDS risk behaviors among later middle-aged and elderly Americans: the National AIDS Behavioral Surveys. Arch Intern Med 1994;154(1):57-63.

(16.) Schable B, Chu SY, Diaz T. Characteristics of women 50 years of age or older with heterosexually acquired AIDS. Am J Public Health 1996;86(11):1616-68.

(17.) Siegel K, Schrimshaw E, Dean L. Symptom interpretation: implications for delay in HIV testing and care among HIV-infected late middle-aged and older adults. AIDS Care 1999;11(5):525-35.

(18.) High KP. AIDS: a disease of the young? Infect Med 1998;15(12):832, 835.

(19.) Skiest DJ, Keiser P. Human immunodeficiency virus infection in patients older than 50 years: a survey of primary care physicians' beliefs, practices, and knowledge. Arch Fam Med 1997;6(3):89-94.

(20.) U.S. Centers for Disease Control and Prevention.

(21.) Johnson M, Haight BK, Benedict S. AIDS in older people: a literature review for clinical nursing research and practice. J Gerontol Nurs 1998;24(4):8-13.

(22.) Skiest, 1996; Adler; Phillips.

(23.) U.S. Centers for Disease Control and Prevention.

(24.) Chen HX, Ryan PA, Ferguson RP, et al. Characteristics of acquired immunodeficiency syndrome in older adults. J Am Geriatr Soc 1998;46(2):153-56.

(25.) Wellons MF, Sanders L, Edwards LJ, et al. HIV infection: treatment outcomes in older and younger adults. J Am Geriatr Soc 2002;50(4):603-7.