The Other, Older Face of AIDS

AIDS cases among people age 50 and older in the US have jumped 22% since 1991, according to the Centers for Disease Control and Prevention (CDC), presenting social and health care challenges unique to a "baby boom" generation that is an ever-increasing percentage of the population.

April L. Winningham, DrPH, National Institute of Mental Health Postdoctoral Fellow at the Medical College of Wisconsin, conducts research at the Center for AIDS Intervention Research (CAIR). She describes the older adult population as "another face of AIDS" requiring prevention and treatment efforts tailored to their needs.

"The largest generation in American history is made up of baby boomers, those born between 1946 and 1964. This group is 76 million strong and is aging," said Dr. Winningham. "One in 25 Americans was age 65 and older at the turn of the twentieth century; by the year 2050, we expect one in every four Americans to be age 65 and older. In addition to all that older adults have facing them, we have to add HIV to the list.

"We know that the face of AIDS is changing. According to the number of HIV infections and AIDS cases, we know that this disease is no longer just the face of gay white men. It's now becoming the face of color and it's becoming the face of women. But we don't often picture that face as an older face, although we should. Since the beginning of the epidemic, 10% to 15% of our AIDS cases have been among people age 50 and older."

The CDC reported nearly 12,000 HIV infections and up to 91,000 AIDS cases among older adults by the end of 2001 (Dr. Winningham noted that there are also many undiagnosed HIV cases that are not included in rates published by the CDC). According to the CDC, between 1996 and 2000 nearly as many older adults were diagnosed with AIDS as those diagnosed in their twenties.

'That Happens to Younger Folks'
Even with such large numbers of affected older adults, Dr. Winningham wrote in Wisconsin AIDS/HIV Update (Summer 2003), "Traditionally, older adults have been left out of HIV prevention efforts, which suggests that older adults are not perceived as a risk group. However, there is a growing body of evidence suggesting that older adults are at risk for HIV infection."

Generational attitudes about HIV/AIDS, in particular attitudes about "safe sex" techniques and a belief that AIDS is a concern for the young, may play a role in the risk of transmission among older adults, said Dr. Winningham.

"In the beginning of the HIV epidemic, one of the early vectors of transmission among older adults was blood transfusion, but since 1985, we've been monitoring the blood supply resulting in a dramatic drop of HIV infections via blood transfusion," said Dr. Winningham. "So what are the other categories of HIV transmission among older adults? Sexual contact is by far the largest contributor and route of transmission for HIV, in this population as well as any population. With older adults, you're talking about a generation that may never have used condoms, may not know how to use them or feel that they do not need to use them. Among many older adults, birth control methods, such as condoms, are no longer an issue.

"Older adults simply don't consider HIV as their problem. Older adults don't see their faces on billboards or on HIV prevention materials. They don't identify with people at risk for HIV, thinking 'that happens to younger folks, it doesn't happen to us.' As a result, you have an older population that's one-sixth as likely to use condoms and one-fifth as likely to get tested compared to their twenty-year-old counterparts."

Dr. Winningham said that older women are also more vulnerable to HIV infection due to physiological factors manifesting as women age, such as reduced vaginal lubrication in menopause and thinning of the vaginal walls. Both of these physiological side effects of normal aging can lead to abrasions and tears during unprotected sex, which increase the risk of HIV transmission.

Awareness Just a First Step
"What's important to note is that the routes of HIV transmission among older adults are the same as among younger adults," said Dr. Winningham. "In fact, HIV transmission among older adults mirrors transmission among younger populations. Men having sex with men is the number one transmission category among older adults who have been diagnosed with AIDS. Like younger populations, we're seeing an increase in HIV infections due to heterosexual contact and due to injection drug use among older adults.

"What I've seen over the past five years since I've been involved in HIV research with older adults is an increased awareness about this issue. There are more research journals such as the Journal of Acquired Immune Deficiency Syndromes (JAIDS) publishing articles exploring the psychosocial issues that affect HIV risk behavior among older adults. And I believe awareness is also increasing among the general public. Colleagues continue to send me newspaper clippings and magazine articles on this topic from around the country. Various agencies are also contributing to this increased public awareness. Public-friendly fact sheets on the topic of HIV/AIDS and older adults have been produced by the National Institute on Aging as well as the Center for AIDS Prevention Studies.

"Programs that specifically reach out to older adults will be critical to stemming the tide of HIV/AIDS among baby boomers. Creating awareness about the need for such prevention programs is just the beginning. With the assistance of research, we can find out what prevention strategies work best among this population. The next step would be to implement these programs within our communities," Dr. Winningham said. "As our large baby boomer generation continues to age, it is worrisome that we are still in the early stages of creating awareness of this problem and that currently, there are only a handful of programs that are looking at dealing with older adults and HIV prevention."

Dr. Winningham is currently analyzing data from her dissertation work with older adults as well as working with a local clinic to explore the effectiveness of new rapid HIV testing techniques. "We need to know what this new rapid test means for clients of all ages, including older adults because their testing rates are so low. Just this month, FDA has approved another rapid test that doesn't require a blood draw or finger stick. In the future, we're hoping to explore the use of both of these rapid tests among older adults in order to increase testing."

Dr. Winningham's future research with older adults will focus on creating prevention interventions, including message development and programs aimed at older adults. "What we're doing at this point is looking at what works with younger populations and making speculations as to what might work with older adults," said Dr. Winningham. "We need more contextual information regarding sexuality among older adults to create effective prevention programs. Therefore, we need more researchers to focus their efforts and attention on this older population."

Dealing with Adult Learners
"We know through research that we have to focus our efforts and tailor our prevention work," said Dr. Winningham. "We recognize that older adults are 'adult learners,' which means that they're independent and they're self-directed. They prefer problem solving and skill building. They don't come to a program as a blank slate and they shouldn't be treated as such. We also recognize that with age does come some physical decline such as declines in hearing and eyesight. Therefore, when creating educational materials specific for this population, we need to pay close attention to audiovisual materials as well as typefaces, colors and formats.

"We also have to be very generationally specific. Again, with older adults, you might be talking about a population that is not necessarily interested in speaking about their personal issues in a group. Therefore, one-on-one interventions might be more appealing to older adults. We're looking at the possibility of peer education among this population. The influence of peers on older adults plays a role in HIV risk behaviors according to our research with older adults in South Carolina."

Testing and counseling is another issue of concern, said Dr. Winningham, adding that perhaps HIV/AIDS testing and counseling may be more acceptable to older adults if it were incorporated into existing medical care settings and into other health-related messages.

"Another interest area for research is the use of various drugs being marketed to the baby boomers, such as Viagra," said Dr. Winningham. "Understanding the impact, if any, that these drugs have on risk behavior for HIV and other sexually transmitted diseases will be helpful in creating prevention programs.

"When talking about our baby boomers, in general, we're talking about a population that is more physically active and healthier than previous generations. Consequently, they may be more sexually active compared to past generations, which combined with a lack of perceived susceptibility to HIV and a lack of knowledge and skills, may lead to more sexual risk behaviors. Successful HIV prevention efforts focused on reducing HIV risk behaviors and increasing HIV testing among older adults will require collaborative efforts among health providers, educators, researchers, public heath officials and community members."

Dan Ullrich
HealthLink Contributing Writer

For more information on AIDS and older adults, visit the National Institute on Aging, HIV Wisdom for Older Women, National Association on HIV Over Fifty or the New York Association on HIV Over Fifty.

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.