HIV and older Americans: Forgotten in AIDS focus?

Denial runs rampant in public perception of AIDS

Sometimes, clinicians and health officials who work with HIV-infected people who are older than 50 may feel like John the Baptist crying out in the wilderness: They talk and talk, and no one seems to be listening.

"Until it’s your grandmother or your mother, it doesn’t become real," says Suellen T. Cirelli, MSN, ARNP, ACRN, clinical coordinator and clinical consult for the Florida Caribbean AIDS Education and Training Center in Orlando.

Older Americans always have accounted for about 10% of the HIV population, but in Florida their share of the epidemic runs to 14% of the population, and the fastest growing rate of people newly diagnosed with HIV are women older than 50, Cirelli says.

At the center’s unadvertised over-50 HIV clinic, the number of people served has jumped from a handful a couple of years ago to nearly 400, Cirelli says. "It’s split 50-50 between men who have sex with men and people infected through heterosexual transmission."

"The rate is higher for women because they don’t know how to negotiate sexual practice; they don’t know their partner’s history of drug use and who they’re involved with at the same time, and so many women are sharing men in that older age group," Cirelli notes. "Especially in the African-American women cohort, there aren’t that many men in the ratio to women, so there’s a lot of sharing going on."

The use of Viagra and other drugs that contribute to more active sex lives among older Americans also plays a factor, and yet, clinicians who prescribe these drugs rarely mention that the person using them should be certain to practice safe sex with condoms, Cirelli says.

Then there is the added dilemma of women who are married to men who have secret lives in which they are having sex with other men, but hiding this from their wives and families. "Wives come in a lot of times after their husband has died, or they are hospitalized, and that’s when they are diagnosed," Cirelli adds. "Unfortunately, at that stage, they’re getting an AIDS diagnosis from a condition that caused them to be admitted to the hospital."

AIDS conditions easily are overlooked among older women because symptoms such as night sweats could be attributed to menopause, Cirelli notes.

Another factor is that women who are post-menopausal have thinner vaginal linings, which makes it easier to become infected with sexually transmitted diseases (STDs), including HIV, Cirelli says.

The sense of reproductive freedom that accompanies women who are post-childbearing age also may be a contributing factor to HIV infection rates, says Victoria Cargill, MD, MSCE, OAR, director of minority research and director of clinical studies for the Office of AIDS Research at the National Institutes of Health in Bethesda, MD.

"Their childbearing is over; the children are out of the house, and there is no fear of pregnancy," she explains. "Plus, they come from a generation for whom condoms are only for dirty people or people who have diseases."

Unfortunately, these perceptions are not the reality for many older Americans. For example, STD data show that for African-American and Latino men, the rates of gonorrhea, syphilis, and chlamydia remain as high for men in their 60s and 70s as for men younger than 40, Cargill says.

Likewise, older African-American women are at greater risk of exposure to HIV through sexual relationships, and this often is a risk they and their clinicians haven’t even considered, she says. "I’d like clinicians to be aware of their own ageism; if you deny someone the role of client because of how they look or what shade of gray their hair is, then you deny them the information they need to make informed decisions."

This is why it’s so important for clinicians to make sexual history taking a routine part of the practice, rather than questions that are asked when a patient appears to be someone who has an active sex life, Cargill says.

When clinicians fail to inquire about their older clients’ risk activities, they may miss an opportunity to give people another decade or two of health and life, Cirelli points out.

"It’s really incredibly important to get older people diagnosed as soon as possible, so that you can boost and support their immune systems," Cirelli says. "Once you lose the older T cells, it’s hard to bring them back, and the literature supports the idea that the older you are when you are diagnosed the more quickly the HIV will course through you and have a terminal outcome."

Prevention programs targeting older women could emphasize the need to introduce condom use early in a relationship and could demonstrate negotiation skills, Cargill adds. An HIV prevention coordinator might talk about how a woman will begin seeing a man, having a drink together; and then one thing leads to another, and they end up in the bedroom, she explains.

By then, it’s difficult to bring up the idea that the man should wear a condom, so a better strategy is for women to develop a habit of bringing up condom use while they’re still in the kitchen talking — long before they reach the bedroom, Cargill suggests.

"Also, it’s harder to introduce the idea of condom use later in a relationship because then it takes on a context that he can interpret as she’s been fooling around on me or she thinks I’m fooling around on her," she says.

"Women can introduce the topic of condoms as a generic, I hear there is so much going around out there,’ type thing," Cargill says. "Then they can bring it closer to home as in, We’ve been seeing each other for a while, and before we have sex, maybe we should talk about how you feel about condoms’; or I think you should use a condom because I care so much about you that even though I think I’m safe, I wouldn’t want to pass anything on to you.’"

Another strategy is for a woman to say to her partner that he is her only partner and she can be his only partner, but if he isn’t comfortable with that, then they would need to use condoms, Cargill adds.