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HIV & Aging Clinical Recommendations
For those at high risk, sexual behavior has more often been defined through the narrow prism of HIV prevention. But, sexual health is broadly defined as more than just the absence of dysfunction or disease. Sexual health is a significant element contributing to the quality of life of every person including older adults living with HIV (Lindau 2007; Liu 2016; Allen 2017).
A recent study (Wang 2015a) noted that there are limited data on the associations between sexual health and physical, emotional, and cognitive function in older adults. How these associations differ by age and sex as well as health status remains unexplored. These associations and interactions must be even more nuanced when the variants of sexual behavior are also considered in the context of cultural norms and local attitudes. These factors can morph across the life-span, especially for the aging older adult with HIV.
In an aging society, medical management and supportive services related to changes in sexual health will increase. These changes are impacted by pharmaceuticals. Viagra sales range from 1.6 to 2 billion dollars annually (Statistics 2017). Lindau’s seminal USA data (Lindau 2007) showed that the prevalence of sexual activity for older adults decreased with age and that the activity numbers reported are driven by primarily by partner availability. Many people, particularly women, “lose” partners from divorce or death or severe illness like Alzheimer’s as they age (Taylor 2015). For women of color in the USA, especially older African American women, partner availability is markedly decreased in their community because of often endemic violence and high rates of incarceration (Taylor 2017a; Committee 2016). Notably, for older women the motivation to seek new relationships is driven not only by desire and pleasure seeking, but also the powerful need for companionship that can markedly reduce fears of loneliness and social isolation (DeLamater 2014; Taylor 1990; Andany 2016). Social isolation is common in older adults and can be asscociated with depression that is poorly managed. For many older adults with HIV social isolation has been constant throughout their life regardless of age (Greysen 2013; Cattan 2005) driven by AIDS driven stigma (NOP 2017; Baugher 2017). This social isolation is manifested in the fact that most of older adults with HIV live alone (mean age less than 60) (Brennan 2011; Brennan 2013; Shippy 2005; Shippy 2005a).
There is evidence that positive sexual health protects against those stresses that arise from chronic illness that characterizes ageing (Ryff 1998). This observation has been often seen in HIV discordant couples (Gamarel 2014a; Gamarel 2014). Research supports the view that a gay couple’s sexual health is a function of the quality of their overall relationship. That relationship, and not social perceptions or approval, are correlated with positive sexual satisfaction (Taylor 2017a; Sprecher 2004; Berg 2007). This can be a significant issue for those living with HIV. Studies (Trotta 2008) found that about half of those with HIV report sexual problems which include sexual dissatisfaction. This is not unexpected since sexual dissatisfaction within couple relationships occurs in the presence of chronic illnesses – HIV being one of those chronic illnesses (Diamond 2012).
Poor quality of life can significantly affect medication adherence as well as patient directed health care decisions that are an integral part of multimorbidity management. Sexual dysfunction can be a side effect of medications (Sewell 2017), be associated with a past medical/surgical history, or, sexual abuse as well as the oppressive effects of stigma (Gesink 2016). The successful integration of sexual health care can decrease morbidity and mortality, and enhance well-being and longevity in the patient (Diamond 2012).
Health-care professionals more often underestimate the desire for and level of sexual activity in the older adult population thereby neglecting their risk for STI exposure (Lindau 2007). In fact, CDC reports that STI diagnoses in those 65 years and older are increasing and similar to trends in the 20-24-year-old age group (CDC 2016b). Quite simply most do not believe that older adults, and especially older adults with HIV, are sexually active. This failure to engage the older adult, and particularly the older adult living with HIV in a conversation about sexual health and the need for safe sex practices has consequences, which include the spread of HIV and other STIs (See Chapter 7 on Detection and Screening for HIV in Older Adults in this series). By not engaging the older adult, medical care providers have been reinforcing the myth that older adults do not have sex. One of the consequences of this prevailing attitude is that with increasing age the likelihood of having an AIDS diagnosis at the time of initial HIV detection increases (Committee 2016). Primary prevention for HIV and STI’s in older adults should be a priority for the medical team. Unless identified and addressed the sexual health of the older HIV+ patient will have a negative impact on health outcomes. As well, secondary prevention to minimize HIV transmission is needed.
Detailed studies have begun to examine sexual behavior in older adults living with HIV/AIDS (Golub 2011; Golub 2010; Szerlip 2005; Lovejoy 2008; Taylor 2015; Lovejoy 2015; Heckman 2014; Ompad 2016). The frequency of unprotected insertive sex is high among older adults with HIV (Golub 2010; Taylor 2015). About 41% of the sexually active older adults with HIV in the ROAH Study report unprotected anal or vaginal sex in the past 3 months (Brennan 2011; Golub 2011; Golub 2010). Different frequencies and patterns of sexual risk behavior have been found among older HIV infected adults by gender and sexual orientation. As an example, older HIV-infected men (regardless of sexual orientation) are more likely to be sexually active compared to women, but condom use rates are lowest among gay and bisexual self-identified males, compared to heterosexuals (Golub 2010; Lovejoy 2008). Studies have also found that older women are at higher risk of STI because of vaginal atrophy that may contribute to increased exposure (Lindau 2007). Older post-menopausal women may perceive the elimination of the risk for pregnancy as extending to the elimination of the risk for STIs including HIV. As older adults living with HIV begin to internalize the emerging consensus that a low or non-detectable viral load is commensurate with low infectivity (but not zero) they are likely to engage in more sexual risk sex behaviors, avoiding the need to disclose their status and not use a condom (Cohen 2011). Also, reports suggest that for various reasons, older MSM have paired with younger MSM, thereby increasing risk (Mustanski 2013). Such increased behavioral risk needs to be discussed at regular visits with appropriate counseling given (Aberg 2009). However, for persons continuing such behavior referral to a program that offers behavioral modification strategies, including group and phone interventions are needed as well as the adoption of PrEP (Aberg 2009; Illa 2010; Lovejoy 2011). (See Chapter 28 on PrEP and Older Adults in this series)
CDC surveillance data (CDC 2014) show that 17% (1 in 6) of all new HIV infections occur at age 50 and older in the US. That incidence rate has increased from 11% in 2002 (CDC 2014). Between 30-40% of sexually active HIV infected adults report unprotected anal or vaginal intercourse (Golub 2011; Golub 2010). Such risk-taking may be associated with less knowledge about HIV/AIDS and recent substance use. Condom use is effective in preventing HIV and STI transmission. However, older persons may not use condoms because they are unaware of the risks. Also, older men can suffer from some degree of erectile dysfunction, which makes condom use less reliable. Topical microbicides for vaginal and anal use by women and men are being developed. Studies show that treatment of an HIV-infected partner in HIV discordant couples reduces significantly the rates of sexual transmission of HIV (Davis 2012; CDC 2013; Conner 2017; Dispenza 2015).
Studies consistently demonstrate associations between unprotected sex and negative affect, including depression and anxiety. Research finds high levels of depression, loneliness, anxiety, and chronic stress across gender, race/ethnicity, and sexual orientation among older adults with HIV (Grov 2010; Heckman 2000; Kalichman 2000; Stall 2003). Distress and mental health problems emerge as critical determinants of risk behavior among HIV infected older adults. (See Chapter 7 in this series Detection and Screening for HIV in Older Adults).
A recent exhaustive report on HIV Prevention and Older Adults prepared as part of the New York State Ending AIDS by 2020 effort provides detailed analyses of prevention efforts as well as detailed implementation suggestions and strategies for every community and environment (Committee 2016).
NIH’s National Institute on Aging provides suggestions as to how to initiate conversations regards sexual health with older adults (NIA 2013). For the practitioner, taking a sexual health history is essential. The following are examples of elements in taking such a history (Nusbaum 2001).
In a 2017 publication (Brennan-Ing 2017) geriatrics fellows reported inconsistent sexual history taking with older adults. The need to include sexual health content in geriatrics trainings was clear. The encountered barriers included competing competencies, lack of educational materials, and discomfort with this topic (Brennan-Ing 2017).
Committee. NEW YORK STATE ENDING THE EPIDEMIC: Older Adults (50+) and HIV. In; 2016.
DeLamater J, Koepsel E. Relationships and sexual expression in later life: a biopsychosocial perspective. Sexual and Relationship Therapy 2014.
Sprecher SC, R.M. Sexual Satisfaction and Sexual Expressions as Predictors of Relationship Satisfaction and Stability. Handbook of Sexuality in Close Relationships Mahwah: Lawrence Erlbaum Associates Inc 2004.
CDC. Sexually Transmitted Disease Surveillance, 2016. Atlanta: US Department of Health and Human Services 2016.
CDC. Diagnoses of HIV Infection in the United States and Dependent Areas, 2013 HIV Surveillance Report 2014; 25.
CDC. HIV Infection Among Heterosexuals at Increased Risk — United States, 2010. MMWR 2013; 62(10).
NIA. Sexuality in Later Life. 2013.