HIV and AIDS in people over 50.

Grow old along with me, The best is yet to be. (from Rabbi Ben Ezra by Robert Browning)

Lovers have long appropriated Browning's reflections on the properties of aging to describe the ideal of a romantic, singular relationship that begins in youth and continues through old age until death.

While, undoubtedly, such imagery becomes the prophecy that structures some people's lives, others arrive at late adulthood looking for romantic or sexual partnering for personal reasons outside the boundaries of a marriage or after having been divorced, widowed, or never married.

Such courtship or sexual pairing in late adulthood carries numerous challenges and possible rewards along with certain drawbacks and risks. One threatening aspect of sexual dating and mating at any age lies in the danger of contracting HIV/AIDS. Despite the common belief that HIV is a young persons disease, 10 percent of all cases of AIDS have occurred annually among people over 50 since the inception of the epidemic. (1)

THE EPIDEMIOLOGY OF AIDS AMONG OLDER ADULTS

Statistics from the Centers for Disease Control and Prevention compiled by Karin Mack and Marcia Ory show that the actual number of AIDS cases diagnosed in adults over age 50 quintupled from 16,288 in 1990 to 84,044 by the end of the year 2000. (2)

Approximately 50,000 Americans in this age group currently live with AIDS, and over 49,965 persons 50 years of age or older have died from the complications of HIV since the start of the epidemic. Some unknown number of those infected or dead contracted the virus after age 50. Others represent instances of survival into late adulthood after more youthful infection.

This latter group is expected to grow substantially over the next decade, due to the success of highly active anti-retroviral therapy (HAART) in prolonging the lives of people with HIV Thus, it can be argued that AIDS is aging both as an epidemic and as a serious health threat affecting older adults.

Transmission routes. People over 50 contract HIV through the same transmission mechanisms as their younger counterparts, although the proportions of cases attributed to any one means may differ.

Early in the epidemic, older persons were infected with HIV disproportionately through the receipt of contaminated blood or blood products during transfusions. (3) This danger has largely disappeared for all age groups since 1985 with the routine screening of blood donations.

Currently, most HIV in people over 50 occurs through male-to-male sexual contact, although this trend is declining somewhat for men of all age groups. Mack and Ory report that men having sex with men accounted for 62 percent of known exposures for males 60 years of age or older in 1994; this percentage dropped to 48.3 percent in 1999. (4) Meanwhile, heterosexual contact has become the primary exposure route for women irrespective of age. Injection drug use, either directly through using contaminated drug paraphernalia or indirectly through sexual partnering with a drug-injector, accounts for a rising number of cases among older adults each year.

HIV RISK FACTORS AFTER AGE 50

As people grow older, a number of physiological changes occurring as part of the aging process influence their sexual behavior and their HIV risk. Among women, normal physiological changes associated with age and sexual functioning include a general atrophy of vaginal tissue and lessening in the rate and amount of vaginal lubrication produced during sexual relations. (6) With age, the clitoral, vulvar, and labial tissue shrink; the size of the cervix, uterus, and ovaries decreases; and some loss of elasticity and thinning of the vaginal wall occurs. Due to possible tearing or abrading of vaginal tissue during intercourse, which permits easier penetration of the virus, women's biological vulnerability to HIV infection increases following menopause.

Among men, normal physiological changes associated with age include reductions in penile myotonia (muscle tension) during sexual arousal. (7) Pronounced reductions in erectile functioning can complicate or thwart using a condom during sexual intercourse. Thus, for some men, fear of inability or the actual inability to sustain a full erection during intercourse can discourage attempts at using a condom to prevent STD or AIDS viral transmission. (8)

Sexual risks. Like all age groups, people over 50 differ in terms of their sexual attitudes, interests, and practices. Such diversity includes personal variation in sexual orientation, initiation into sexual relations, health, partnering experiences, and the effects of major life decisions that facilitate or restrict opportunities for sexual activity. The additive consequences of these multiple influences create differing profiles of sexual behavior and HIV risk for individuals of any age.

Many misconceptions and stereotypes exist concerning the sexual behavior of people over 50. Such fallacies contribute to an older person's risk for HIV and limit successful prevention efforts. Common stereotypes, for example, hold that sexual behavior becomes infrequent or nonexistent in late adulthood. Popular culture, as expressed through birthday cards, comedy routines, and media imagery; often assumes or plays up old age as a time of sexual dysfunction and lack of libidinal interest. (9) Scientific evidence does confirm that sexual arousal slows and sexual activity lessens as people grow older. (10) Yet, considerable evidence also shows that sexuality remains an important part of people's lives well into old age, (11) as does risk for HIV/AIDS. (12)

Older adults who are not sexually active cite debilitating illness and lack of a partner as two major factors that limit sexual activity in late adulthood. (13) For those who seek a mate, romantic pairing, or recreational sex, the pursuit of a partner carries some level of HIV risk. For example, today's older adults who are widowed or divorced face a dating scene quite different in terms of sexual culture and permissiveness from that of their youth and young adulthood. (14) As a consequence, the normative framework that shaped decision-making about sexual behavior in their youth may prove outdated or inadequate when navigating contemporary sexual relationships and social environments that carry HIV risk.

Older adults find sexual and romantic partners in the same way and in many of the same settings that younger people do. Besides potential possibilities for partnering with individuals who are older or younger, people over 50 also come into contact with their own age-peers through senior centers, nursing homes, retirement communities, singles' clubs, and neighborhood bars that cater to an older crowd. The Internet also has emerged as an increasingly popular means for adults of all ages to find romantic or sexual partners. (15) Adults over 50 years of age represent the fastest-growing group on the Internet, (16) and undoubtedly some unknown number avail themselves of this matchmaking benefit. Numerous Web sites targeting both younger and older adults offer opportunities for developing personal relationships. Of course, from the standpoint of HIV transmission, social relationships that begin and remain online are free of HIV risk. Yet, mounting evidence shows that romances that start online have a tendency to m ove offline into face-to-face encounters. (17) How many of these connections carry the potential for HIV risk is unknown. Several recent studies, however, have traced transmission of the virus to contacts first made via the Web. (18)

Drug-related risks. As is also true for sexual behavior, numerous myths and misconceptions exist concerning the prevalence and practices of drug use in late adulthood.

For many years, clinicians and researchers assumed that individuals who use illegal drugs mature "out of the life" (19) and away from HIV risk by the time they reach 50 years of age. Findings from more recent studies, however, have severely challenged this belief.

For example, Alan Richard and his colleagues examined risk behavior for a national sample of 22,289 out-of-treatment crack cocaine and injection drug users to determine the effects of aging on HIV risk. (20) Multivariate analyses showed that projected risk for the sample increased steadily across age-cohorts from younger to older.

For example, 18 to 20 year olds in the sample had an overall 33 percent 10-year projected risk of becoming infected with HIV if they continued to engage in the same drug-related risk behaviors of the last 30 days. Respondents in the sample 61 years of age or older had a higher overall projected risk of 45 percent.

Using the same national database for analysis, Carol Kwiatkowski and Robert Booth also found that sexually active, older drug users engaged in risky sexual behavior at rates similar to that of their younger counterparts. (21) Of the two-thirds of the older cohort in the sample who were sexually active, approximately one-third had engaged in sexual relations with two or more partners in the prior month, exchanged sex for drugs or money and/or had sexual relations with a drug injector.

Nonetheless, nearly two-thirds of those who were sexually active reported never using condoms. Perhaps not surprisingly, older users in the sample had an infection rate of nine percent.

LIVING WITH HIV/AIDS IN LATE ADULTHOOD

Successful treatment of AIDS begins with diagnosis. When compared to younger individuals, older adults tend to be diagnosed with AIDS later in their disease trajectory. (22) Multiple reasons help to explain this lag.

First, health care professionals appear slow to recommend HIV testing for older patients because they often do not perceive people over 50 to be at risk. (23) When same-sex behavior or drug use is suspected of a patient, providers may avoid discussing HIV out of fear of insulting or angering the person. Also, AIDS in its earlier stages often successfully mimics chronic illnesses and conditions common among older patients. (24)

Thus it appears that for some older persons, HIV testing only occurs when symptoms of AIDS become so advanced that they are difficult to ignore or mistake for other conditions. As a result, older individuals tend to have a lower CD4 cell count and a higher plasma viral load than their younger counterparts when their HIV-1 sero-status is first identified. (25) Also, they tend to experience shorter survival intervals following diagnosis.

Treatment. As is also true of HIV risk, the biological properties that accompany aging influence older persons AIDS prognosis, treatment, and illness trajectories.

Unfortunately, from the standpoint of effective medical treatment when clinically managing HIV among older individuals, little is known of how the processes of aging interface with AIDS as a progressive disease. Co-morbid conditions commonly associated with aging are believed, but not proven, to accelerate AIDS disease progression. (26)

Immune senescence, which occurs through repeated cell replication over the life course, also may contribute to rapid declines and lessened response to antiviral treatment in late adulthood, but the role of cellular deterioration in affecting HIV treatment is not well understood and open to argument.

When compared to younger individuals, older persons with HIV report less energy more fatigue, lower quality of life, and greater isolation from family and friends and other supportive networks. (27) Despite such grim research findings, however, any discussion of living with HIV begs attention to the recent development of HAART and other medications that prolong living and quality of life for persons with HIV at all life stages.

The social stresses and potential for severe to fatal health complications associated with AIDS can be great at any age, but as is true of their younger counterparts, people over 50 infected with the virus report that they can and do live productive and satisfying lives.

PREVENTING HIV/AIDS AMONG OLDER ADULTS

Few AIDS prevention programs currently target people over 50. Perhaps this neglect helps to explain why older persons at HIV risk are less likely than their younger counterparts to have adopted AIDS-prevention strategies.

Many proven HIV-prevention methods likely succeed with individuals at any stage of the life course and can be adopted when designing and offering AIDS programming for older adults. Still, the epidemic does appear to manifest itself differently in critical ways among people 50 years of age and older. A number of age-specific interventions based on these differences appear promising.

Biological strategies. Hormone replacement through oral supplements, genital creams, and natural nutrients offers a logical method for reducing HIV risk among older women who experience age-related vaginal changes that encourage viral transmission.

Meanwhile, although far from the only means for treating male sexual dysfunction, the prescription drug Viagra[R] has proven highly successful in increasing erectile function in men, (28) an outcome that can enhance the likelihood of successful condom use.

While medical treatment for the biological changes associated with aging in both sexes can increase sexual enjoyment and possibly reduce physiological conditions associated with increased risk for viral infection, these medical measures are not without possible iatrogenic effects that should be thoroughly discussed with a medical provider. (29)

Educational strategies. Research shows that older people are generally knowledgeable about HIV and its transmission. (30) Yet few older people see themselves at risk even when engaging in high-risk behavior.

Programming in senior centers or retirement communities where older people gather for health information rarely addresses sexuality or AIDS, and few opportunities exist for older adults to increase self-awareness of HIV risk through discussion with others. (31) Thus, mounting successful prevention efforts for people over 50 includes developing and offering age-appropriate educational interventions to increase such awareness.

Most older adults gain their information about sexuality from books or magazines, according to a recent AARP survey. (32) These media resources offer an excellent venue for promoting AIDS-prevention messages as they already reach a ready and interested older audience.

Health care providers also serve as a traditional source of health information for older patients. But many providers lack the time, training, or skills to talk about sex or HIV with older patients. Special training in educating and treating older adults with regard to HIV/AIDS is sorely lacking but critically needed for health professionals. (33)

It bears repeating that people over 50 are not homogeneous in terms of their sexual attitudes, interests, or practices. To prove successful, AIDS-related programming and messages must acknowledge that aging is experienced among older adults according to such diverse factors and personal characteristics as socio-economic status, sexual orientation, gender, race, ethnicity, and health.

Members of the baby boom generation, for example, grew up in a time when sexual and drug experimentation was more widespread than in earlier decades. (34) Their orientation toward HIV risk and prevention in later adulthood likely differs from that of individuals reared during previous eras when sexual relations before marriage and drug experimentadon and use was less common across the general population.

Similarly, among men who have sex with men, those who are now in their twenties have personally experienced little of the population devastation that AIDS exerted on the gay community in many urban centers in the l980s. This age-cohort brings a different perspective to sexual risk and prevention than those who lived through this period as sexually active adults. (35)

Identifying and addressing such differences among older adults and age-cohorts is essential when designing and offering AIDS educational and intervention programming.

Safer sex. Sexual behavior includes a wide range of erotic practices that do not require a partner and/or an exchange of body fluids carrying HIV risk.

Enormous sexual gratification can be found in masturbation, sexual fantasies, cuddling, kissing, reading erotic literature, nongenital petting, and caressing. Adults of all ages can enjoy these sensual experiences, and they offer an effective way to avoid the threat of AIDS for those who choose not to engage in penetrative sex. They also can become an important means of interpersonal connection and mutual pleasure when one partner in a sexual relationship or encounter is HIV infected, and the couple chooses not to have intercourse.

Latex condom use during sexual intercourse remains a primary and effective means to avoid and curb transmission of the virus for all age groups. A study on condom use conducted by Durex, however, found that older adults are more resistant to using condoms and modifying sexual behavior than their younger counterparts. (36) Similarly, in surveying over two thousand adults aged 50 and over, researchers Ron Stall and Joseph Catania found that only a small percentage with a known behavioral risk for HIV infection reported using condoms during sexual intercourse. (37) Among those engaging in some HIV risk behavior without using a condom, more than 63 percent indicated having multiple sex partners.

Successfully promoting safer .sex to prevent HIV/AIDS requires some attention to personal sexual history; cohort effects, prior experience, and gender differences.

As noted earlier, adults over 50 years of age differ in terms of their exposure to and life experience with the availability and use of condoms and other contraceptive devices. Baby boomers now entering their fifties typically reached sexual maturity in the wake of the development of "the pill" for contraception. Those who opted in their youth for the convenience and freedom of oral contraceptives may have little first-hand experience with successfully using a barrier method that requires immediate application before intercourse. Meanwhile, for older individuals in their seventies and eighties, having come of sexual age prior to the availability of the pill, condoms constituted one of the more popular contraceptive devices. Given such variation in experience and exposure, older adults likely require different information, skill-building opportunities, and encouragement if they are to practice safer sex.

Due to both male biology and the dictates of power relationships as codified through traditional gender norms, men typically have assumed the rights and responsibility for initiating the use of male condoms in a sexual encounter. (38)

The recent development of the female condom provides women of all ages with a form of barrier protection against HIV that does not rely on male initiation or cooperation. Inserted into the vagina using a special lubricant developed for this purpose, women typically need some training in how to do this if they are to use them successfully. (39) Unfortunately, no research to date appears to have investigated the barriers and facilitators to successful female condom use by older women with disabling disorders or pronounced age-related vaginal changes. Still, the female condom offers a promising alternative to the male sheath for those older women who want greater personal control over reducing their HIV risk.

Safer drug use. Among illicit drug users, outreach strategies that provide AIDS education and promote safer needle behavior have proven successful in reducing HIV transmission related to injecting drug use. (40)

Sexual transmission that occurs within the context of illicit drug use, however, has proven far more difficult to successfully curb through outreach services and bears more research and programmatic evaluation. (41) Syringe exchange programs also show excellent results in reducing AIDS transmission in geographic areas where they are legal. (42)

Older addicts, however, don't necessarily benefit from these risk reduction offerings. A study of older street addicts, for example, found that outreach services can miss older users, as the latter tend to be less accessible for prevention than their younger counterparts. (43) Moreover, ill health and chronic disabilities common to old age can restrict the ability of older persons to travel to syringe exchange sites to obtain needle-hygiene supplies. Fear of victimization in these settings by younger users also inhibits program use.

Such deterrents point to the need for developing and offering age-sensitive services that target older users as an often hidden and difficult to access high-risk group.

CONCLUSIONS

Late adulthood can be highly rewarding, as Robert Browning's poetry contends and much research confirms.

Sex is an important part of this life stage for many older adults, and considerable evidence suggests that sexual activity continues throughout the life course, bringing pleasure, better health, and improved subjective well-being.

HIV/AIDS need not curb sexual enjoyment among older adults nor spoil or shorten this later stage of life. Armed with adequate knowledge about AIDS and motivation for its prevention, people of all ages can avoid infection. New treatment options also offer strong hope for both lengthening and enhancing the quality of life for those already infected with the virus.

Thus the rewards of late adulthood, including sexual and romantic partnering, can indeed live up to Browning's promise of being among life's "best".

REFERENCES

(1.) K.A. Mack and M. G. Ory, "HIV/AIDS and Older Americans at the End of the 20th Century." (Paper presented at the conference sponsored by the National Institute on Aging on HIV/AIDS and Aging: Designing and Evaluating Interventions for Older Adults, Washington, DC, Sept. 20-21, 2000.)

(2.) Ibid.

(3.) R. Stall, J. A. Catania, and L. Pollack, "The Social Epidemiology of AIDS and HIV Infection among Older Americans," in M. W Riley, M. O. Ory and D. Zablotski, editors, AIDS in an Aging Society (NewYork: Springer, 1989), pp. 60-76.

(4.) K. A. Mack and M. G. Ory, "HIV/AIDS and Older Americans at the End of the 20th Century." (Paper presented at the conference sponsored by the National Institute on Aging on HIV/AIDS and Aging: Designing and Evaluating Interventions for Older Adults, Washington, DC, Sept. 20-21,2000.)

(5.) J. A. Levy, "AIDS and Injecting Drug-Use in Later Life," Research on Aging, vol. 20, no. 6, pp. 776-97.

(6.) G. Bachmann, "Influence of Menopause on Sexuality [Review]," International Journal of Fertility and Menopausal Studies, vol. 1, pp. 16-22.

(7.) W. Masters and S. Johnson, Human Sexual Response (Boston: Little Brown, 1966).

(8.) J. A. Levy, "AIDS and Injecting Drug-Use in Later Life," Research on Aging, vol. 20, no. 6, pp. 776-97.

(9.) R. N. Butler and M. I. Lewis, Love and Sex after Forty (NewYork: Harper & Row, 1986).

(10.) W. Masters and S. Johnson, Human Sexual Response (Boston: Little Brown, 1966).

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(12.) S. Broom, "Sex Happens after 50 and So Do Sexually Transmitted Diseases," SIECUS Report, vol. 27, no. 3, pp. 12-13.

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(34.) M. W. Riley, "AIDS and Older People: The Overlooked Segment of the Population," in M. W Riley, M. G. Ory, et al., AIDS in an Aging Society: What We Need to Know (New York: Springer, 1989), pp. 3-26.

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(38.) J. Holland, C. Ramazanoglu, et al., "Pressured Pleasure: Young Women and the Negotiation of Sexual Boundaries." (Paper presented at the British Sociological Association Annual Conference, Manchester, England, 1991.)

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(40.) S. R. Friedman, R. Curtis, et al., Drug Injectors' Lives and HIV/AIDS (New York: Kiuwer Press, 1999).

(41.) R. C. Stephens, C. F. Kwaiatkowski, and R. E. Booth, "The Impact of the NIDA Cooperative Agreement Programs on HIV Risk among Crack and Injection Drug Users," in J. A. Levy, R. C. Stephens, and D. C. McBride, editors, Advances in Medical Sociology, vol. 7 (Stamford: JAI Press, 2000), pp. 241-59.

(42.) T. S. Jones and D. Vlahov, "Use of Sterile Syringes and Aseptic Drug Preparation Are Important Components of HIV Prevention among Injection Drug Users," Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology, vol. 18, no. 1, Pp. S1-S6.

(43.) T. L. Anderson and J. A. Levy, "Social Isolation, Perceptions of Risk, and HIV Prevention: A Mixed Method Study of Older Injecting Drug Users." (Poster presented at the National HIV Prevention Conference, Atlanta, GA, 1999.)