Are sexually active older Americans your next high-risk group?
August 1, 1999 6 minutes read
Are sexually active older Americans your next high-risk group?
CDC says more older people are contracting HIV through sexual contact
When Jane Fowler, 64, began dating in the mid-1980s, she was a little rusty, having gone through a divorce in 1983 after 23 years of marriage. However, by the end of the decade, the Kansas City, MO, resident knew enough about AIDS to be concerned that she could be at risk. In 1989, Fowler asked her long-time family practitioner if she should take an HIV test.
"Oh no, not you, Jane Fowler," her doctor answered lightly.
Fowler found her doctor’s response comforting. She put the possibility of AIDS out of her mind until she received an ominous letter from an insurance company in January 1991. Her application for a new health insurance policy was denied because of a "blood abnormality." She spent a sleepless night and anxious next day until the insurer faxed the results to her doctor. The same doctor who had earlier brushed off her interest in an HIV test now gave her the bad news: "Jane, your insurance company claims your blood tested positive for HIV."
Fowler, who later determined that she had become infected on New Year’s Eve in 1985, says she hopes things are different today and family doctors don’t brush off a middle-aged patient’s request for an HIV test.
"Obviously, if someone starts talking about HIV, then maybe doctors should have a sense that the person has some concerns and there was a behavior that could lead to infection," says Fowler, who now serves as speakers’ bureau coordinator with the Good Samaritan Project, an AIDS service organization in Kansas City. "And by all means, the provider should follow through and offer testing."
However, despite the progress made in the field of HIV/AIDS treatment and all the education information disseminated to the public, physicians and others who work with older HIV patients say the health care profession still treats older people as though they are celibate and therefore at no risk of contracting the virus.
"There’s a tremendous amount of education needed," says Mary Lynn Kasunic, MS, RD, executive director of the Area Agency on Aging, Region One, in Phoenix. "Physicians often don’t acknowledge that seniors are still sexually active."
Statistics present a different picture. Until the 1990s, elderly Americans were disproportionately infected by contaminated blood supplies, with a risk factor of 6% for those in their 50s, 28% for people in their 60s, and 64% for those age 70 and over.1 Now the risk of contracting HIV from blood transfusions is negligible, but increasing numbers of older adults are becoming infected through their sexual behavior, according to the Atlanta-based Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report.
According to 1996 figures, the most recent figures available from the CDC in this category, only 2.4% of HIV-positive people ages 50 and over were infected with HIV from blood products. Another 19% were infected through injecting drug use. About 36% of those infected were men who had sex with men, and 14.5% reported they were exposed through heterosexual contact. This compares with 12.7% of people ages 13-49 who were exposed through heterosexual contact. Because nearly 26% of the older adults reported no reason for exposure, the number of cases relating to sexual behavior could be higher.
About 11% of all AIDS cases reported in 1996 were among people ages 50 and up. The CDC reports that this percentage has remained stable since 1991. However, the CDC notes an alarming trend in that older AIDS patients had a greater increase in opportunistic infections (OI) than did younger AIDS patients. The older age group’s OI incidence rate rose by 22%, vs. a 9% increase among the 13-49 age group. The report also says a higher proportion of people aged 50 and above died within one month of AIDS diagnosis.
Older people diagnosed later for infection
The CDC concludes that people ages 50 and above are diagnosed later in the course of their HIV infection than younger people are, and they may not be promptly tested for HIV infection following the onset of HIV-related illnesses.
These statistics seem to confirm the idea that older adults are naive about their risk of contracting HIV and their providers aren’t discussing that risk with them. A 1997 study of Texas doctors found that most physicians rarely or never discussed HIV and risk factors with their older patients.2
"I’m concerned that there are older people out there who may have the virus, and no one is really alert enough or paying attention to the fact that HIV may be a possibility," says Mary Ann Malone, CSW, case manager of adult AIDS clients at Mt. Sinai Hospital in New York.
Compounding the problem, AIDS symptoms often are more difficult to diagnose in older people because they mimic some common diseases associated with old age, says Nathan L. Linsk, PhD, professor of social work at the Jane Adams College of Social Work in Chicago and the principal investigator for the Midwest AIDS Training & Education Center at the University of Illinois at Chicago. Linsk is a co-founder and co-chair of the National Association on HIV Over Fifty.
"HIV-associated dementia might be confused with multi-infarct dementia or other diseases," Linsk explains.
Physicians should ask about sexual behavior
For these reasons, physicians should keep HIV in mind as a possibility, even with their older patients. Malone and other HIV experts recommend physicians routinely ask all patients about their sexual behaviors during the annual physical or gynecological exam. Or if they are uncomfortable doing so, they could simply add a question about sexually transmitted diseases or sexual risk behaviors on the patient’s medical history form.
"And secondly, providers should educate the population over 50 about possible exposures to HIV and safer sex practices," Malone says.
One of Malone’s clients is a 72-year-old HIV-positive woman who probably contracted HIV through sexual intercourse, although her partner had not been diagnosed before he died of an ear infection. The woman began to develop a few symptoms of HIV infection, and her physician suggested that she be tested. "He was more alert to the fact that this could be a possibility," Malone says. "So there are always these very hopeful signs that the message is getting through."
Some agencies that offer support services to older people and the Washington, DC-based American Association of Retired Persons (AARP) now try to get the word out to their audience about HIV and safe sex. AARP has a video about HIV titled "It Can Happen To Me," and the Phoenix agency distributes HIV brochures titled "AIDS is Ageless - Practice Safe Sex" and "Don’t Gamble with HIV/AIDS."
But there’s little federal support for these efforts.
"When you apply for national grants for HIV prevention education, the government is focused on groups like teenagers or men having sex with men," Kasunic says. "In the last five to six years, when we’ve applied for grants, they always send it back and say, This is not one of our targeted populations.’"
Meanwhile, the few agencies that are trying to get the word out to older people face an uphill battle.
The Phoenix Area Agency on Aging has sponsored four free suburban HIV testing sites that were marketed to seniors in the same way as a blood pressure or cholesterol screening, but these offered anonymity. In all, 40 people showed up for tests.
"It’s been real disappointing, because we were hoping we’d have a groundswell from the community saying, I want to be tested,’" Kasunic says. "We’d thought some of the problem was older people didn’t want to go to the county health department, and they didn’t want to drive into the city, so we thought we’d take it out there to them."
The stigma of HIV is still so high among the elderly that even when people have engaged in risky behavior, they often are afraid to be checked. (See related story on treating older HIV patients, at right.) For example, Kasunic recalls that one woman who came to a portable testing site said she and three other women in her apartment complex were having sex with the same man. The woman had lost a straw draw and was selected to come down to the site for testing. The four women figured that if one of them tested positive, they would all have something to worry about. Her test was negative.
Kasunic says she can understand an older woman’s reluctance to demand that her partner use a condom. "If you’re in your 60s or 70s, and the ratio of men to women is not so good, and you finally find someone to become intimate with, I don’t know if you’d want to demand the man use a condom," she explains. "If you get too demanding, he might move on to another woman because he has lots of choices."
References
1. AIDS among persons aged >50 years — United States, 1991-1996. MMWR 1998; 47:21-26.
2. 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; 6:289-294.
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