| Please note: This is a working draft only. All text is subject to revision and correction of inadvertent errors and misinterpretations of theories and research findings. |
HIV/AIDS is a devastating worldwide pandemic, impacting not only those who are infected, but also their families, the healthcare system, the economy, and the political sphere. The World Health Organisation estimates that 14 million people worldwide are infected with HIV, and that 4 million of those have developed full-blown AIDS (American College of Physicians, 1993). In the United States, there are nearly half a million reported AIDS cases, and it is estimated that more than 1 million individuals are infected with HIV (Centers for Disease Control, 1995). That estimate is expected to jump to 7 million over the next 20 years. Every day in the United States, more than 100 people die of AIDS (Centers for Disease Control, 1991). By 2010, annual AIDS-related health expenditures are expected to be over $50 billion (Puleo, 1996; Zelenetz & Epstein, 1998).
Although HIV/AIDS typically affects young and middle-aged adults, 10% of HIV infections[1] occur in individuals 50 years and older (Centers for Disease Control, 1993; see also Appendix "A"). Alarmingly, this rate has been steadily rising since 1982 (Gaeta, LaPolla, & Melendez, 1996; see also Appendix "B"). In areas with concentrated senior populations, such as Florida's Palm Beach County, infection rates in this age group are as high as 15% (Speyer, 1994, cited in Puleo, 1996). When we consider under-reporting, missed diagnoses, and revision of HIV diagnostic criteria to include such diseases as Kaposi's sarcoma (see Appendix "C"), these rates of new infection may be even higher (Talashek, Tichy, & Epping, 1990). While HIV infection in seniors can easily occur through injection drug use (Levy, 1988) and while transmission through blood transfusions (Centers for Disease Control, 1993; Catania, Turner, Kegeles, Stall, Pollack, 1989) is not yet impossible, the majority of new infections appears to be due to risky sexual behaviours (Bachus, 1998; Stall & Catania, 1994).
These rising infection rates are disturbing for many reasons, not least of which are the fact that there is no cure for HIV/AIDS and that these new infections are contributing to the over-all spread of the HIV virus. Additionally, the implications of HIV/AIDS are different for older individuals than they are for younger individuals. Not only does HIV/AIDS destroy an immune system already weakened by ageing itself, but in older individuals its progression is more rapid and unrelenting (Szirony, 1999; Whipple & Scura, 1996); it is complicated by other chronic conditions; and it thus adds to the over-all amount of care these individuals require from the formal healthcare system. Furthermore, older HIV/AIDS patients may be less likely than younger patients to have the informal care and social support afforded by friends and family (Speer, Kennedy, Watson, Meah, Nichols, & Watson, 1999). They may also experience more isolation, loneliness, and depression (Nocera, 1997).
The significant rates of sexually transmitted infection in the elderly point to the need for effective behavioural risk-reduction programs. Sexual education has shown significant promise in reducing risky sexual behaviours in this age group (Stall & Catania, 1994; Rose, 1996). This paper will examine education-based programs that draw on aspects of two useful models: the Health Belief Model and the Theory of Reasoned Action. The Health Belief Model can be used to determine optimal sexual education material and the most effective teaching procedures. The Theory of Reasoned Action can illuminate how beliefs and attitudes can affect sexual behaviour change. Education programs can then be tailored to attempt to change these beliefs and attitudes.
HIV is a disease that weakens or destroys the immune system by attacking white blood cells. It is caused by infection with a retrovirus (HIV) in combination with host-specific factors that are to date unclear. HIV attaches to immune system cells, injects in them its viral core, and then becomes part of the host's immune system. The host remains infected until death. HIV[2] enters the body through infected bodily fluids, including blood, semen, vaginal secretions, and breast milk. Entry typically occurs through sexual contact (e.g., vaginal and anal intercourse[3]), the sharing of needles and other instruments contaminated with blood, and, more rarely today, blood transfusions (Linsk, 2000). Transmission can also be in-utero. HIV is identified as having 3 stages (Centers for Disease Control, 2001): an HIV-asymptomatic stage (which can last as long as several years); an HIV-symptomatic phase (also known as AIDS-related complex, or 'ARC'), and AIDS. An individual is diagnosed with AIDS when s/he develops such conditions as opportunistic infections (see Appendix "C"), unusual cancers, wasting, AIDS-related dementia, or significant decrease in T4 white blood cell count (< 200, or fewer than 14% of total white cells). To prevent infection, individuals must minimise those behaviours which put them at higher risk of coming into contact with infected bodily fluids.
Despite popular beliefs to the contrary (e.g., Schlesinger, 1996), seniors are not asexual (Kinsey, Pomeroy, & Martin, 1948; Kinsey, Pomeroy, Martin, & Gebhard, 1953). While overall rates of sexual activity do generally decrease with age, a large percentage of seniors still engage in regular, satisfying sexual activity, including hugging, kissing, petting, oral sex, and intercourse. In a representative community sample of married individuals, Diokno, Brown, and Herzog (1990, cited in Barlow & Durand, 1995) found that 75% of men and 64% of women aged 65-69 were still sexually active. In the 70-74 age group, these figures were 58% and 43%, respectively. Most illuminating, however, were the rates for the 80+ age group: nearly 30% of men and 25% of women were still sexually active! As Wiley and Bortz (1996) write about the seniors in their study of the effectiveness of a sexual education program, "[many exhibited] a remarkably robust sex life. . .even until advanced old age." Clearly, many seniors are sexually active just like younger people—in some cases, even more so (see also Siegal & Burke, 1997).
Yet many of these older individuals unknowingly engage in sexual activity that places them at high risk for HIV infection (Feldman, 1994; Ory & Mack, 1998; Zelenetz & Epstein, 1998; Gordon & Thompson, 1995). The highest risk behaviour for those aged 50 and over is male-male sex with an infected partner (anorectal, oral-anal, and digital-anal sexual intercourse[4]), with nearly 60% of all HIV infections caused by this means (Puleo, 1996; Grossman, 1995; Van de Ven, Rodden, Crawford, & Kippax, 1997). Heterosexuals, however, are also at risk. HIV transmission through heterosexual sex with an infected partner has increased dramatically, from hardly any before the mid-1980's to 10% of all infections by 1990. As Stall and Catania (1994) point out, heterosexual HIV transmission is higher in this age group than in any other. Use of effective barrier methods, such as latex condoms, dental dams, and rubber gloves, is rare among sexually active seniors (Schable, Chu, & Diaz, 1996; Center for Women Policy Studies, 1994; Stall & Catania, 1994).
Another risky behaviour is having multiple sexual partners, which is not uncommon among widows and widowers (Bulcroft & Bulcroft, 1991). This is especially dangerous when one is unaware of the partner's sexual history and HIV/AIDS status. The older man who engages the services of anonymous prostitutes and hustlers for hetero- or homosexual contact is also not unheard of (Ankrom & Greenough, 1997; Anderson, 1996). Furthermore, older individuals are not very likely to be vigilant for unusual rashes, discharges, or genital lesions that may be indicative of a sexually transmitted disease (Talashek, Ticky, & Ebbing, 1990). Finally, it should be noted that ageing itself puts seniors at an even greater risk for HIV infection. Dry, thinner vaginal walls associated with menopause may increase the risk of vaginal tears and thus create portals of entry for HIV. Thus another risky behaviour is engaging in sexual activity without making accommodations for these normal age-related changes (e.g., not using vaginal creams and lubricants before intercourse).
Seniors are less likely than younger individuals to engage in safer sexual practices for reasons that are beyond the scope of this paper. Two reasons, however, are noteworthy. First, seniors have lived most of their lives at a time when HIV was unheard of; thus, safer sexual practices were not seen as crucial as they are today. Second, for the majority of their lives, most have had sex only with their spouses. In the context of a monogamous, lifelong relationship with a partner presumably free of any sexually-transmitted diseases, using condoms and other prophylactics was rarely seen as a necessity. Put more simply, seniors are just not accustomed to today's safer sexual practices.
As Puleo (1996) aptly points out, "educating the public regarding how HIV is transmitted, behavioral risks, and prevention are basic to the effort to reduce infection within all populations" (p. 3). These efforts have led to reductions of risky sexual behaviours in younger age groups, particularly among individuals in very high-risk categories (e.g., gay males). Such programs have been effective particularly because they are based on sound theoretical foundations. Indeed, as Salazar (1991) reminds us of many unsuccessful programs, "they lack a theoretical foundation. A program may be mandated and implemented without considering the complexities of human behavior, and with little concern for the difficulties in changing behavior" (p. 128).
However, successful programs based upon sound theoretical foundations have not been targeted to older individuals. This has been due in large part to ageist beliefs among health promoters and healthcare providers that older individuals are not sexually active and thus not at risk for HIV infection (Feldman, 1994; Szirony, 1999; Hillman, 1999). Indeed, healthcare providers know little about HIV risk factors in the elderly or even how to recognise HIV in this population (Skiest & Keiser, 1997; El-Sadr & Gettler, 1995; Szirony, 1999; Mack & Bland, 1999). The effects of this have been disturbing. In the National Health Interview Survey of 1992 (Schoenborn, Marsh, & Hardy, 1994, cited in Puleo, 1996), 77% of elderly respondents believed they had no chance of contracting HIV. Compared with younger individuals, older persons know little about the HIV virus or how it is transmitted (Rodgers-Farmer, 1998; Wright, Drost, Caserta, & Lund, 1998; Zablotsky, 1998; Strombeck & Levy, 1998). They know even less how HIV is not transmitted (e.g., through casual contact, sneezing, coughing, or in swimming pools and hot tubs; Strombeck & Levy, 1998; Rodgers-Farmer, 1998). Older individuals are also less likely than younger persons to know where to go to get tested for HIV (McCaig, Hardy, & Winn, 1991). In general, lack of knowledge of HIV and of risk of infection is higher in this age group than in any other (Puleo, 1996).
A significant concern for health promoters working with older individuals is that "even after the best education, clients often make no change or practice the healthy behavior for only a short time, then revert back to their previous unhealthy patterns" (Burbank, Padula, & Nigg, 2000, p. 26). It is interesting, however, that while this may be the case for many of the behaviours that are common targets for health promotion—smoking cessation, nutrition, exercise—it does not appear to be the case for safer sexual practices. The traditional method of changing behaviour through education appears to have positive, lasting results. Indeed, for the 50+ age group more than any other, merely teaching that HIV can occur in older individuals and communicating the specific behaviours that can increase infection risk are often by themselves sufficient for behaviour change. As Stall and Catania (1994) determined in a study of the 1992 National AIDS Behavioral Surveys, when older individuals are made aware of transmission risks, they are able to—and indeed do—reduce these risky sexual behaviours, especially when they understand the connection between the behaviours and HIV/AIDS prevention (see also Bausell, 1986). For this reason, recommendations for primary prevention almost universally place most emphasis on various educational strategies (see Appendix "D")[5]. The few sexual education programs that currently show promise draw on various useful aspects of the Health Belief Model and the Theory of Reasoned Action.
The Health Belief Model ('HBM', Rosenstock, 1997) is a comprehensive behaviour change model that emphasises an individual's subjective perceptions of health. According to this model, the likelihood that a person will engage in a health-related behaviour is based upon his/her 'readiness to act'. Readiness to act is determined by four factors: 1. one's perceived susceptibility of getting a disease; 2. one's perception of the severity of the disease; 3. one's perception of the efficacy of the suggested behavioural changes in reducing the likelihood of getting the disease; and 4. one's perception of the costs (barriers) associated with performing the health behaviour. A person would be likely to perform the behaviour if, for instance, she perceived her risk of disease to be high; felt the disease would at least moderately affect her life; believed adopting the behaviour would reduce disease risk; and did not feel there were many barriers to adopting that behaviour.
The HBM model additionally proposes that 'cues to action' activate readiness and stimulate actual behaviour. Such cues include newspaper/magazine articles, mass media campaigns, brochures from doctors' offices, and advice from others. A recent addition to the model is the concept of 'self efficacy'—one's confidence in the ability to perform the desired behaviour. Directly and indirectly, these factors are all modified by such variables as demographic characteristics (age, sex, race, etc.); sociopsychological variables (personality, social class, reference group pressure, etc.); and structural variables (knowledge about the disease, prior contact with the disease, etc.). The Health Belief Model has shown empirical validity when prevention of accident and disease is the objective (Janz, 1984, cited in Salazar, 1991). Thus, it is particularly suited for HIV/AIDS prevention.
All programs that raise perceived susceptibility and knowledge are critical for HIV/AIDS prevention. Indeed, as Skiest and Keiser (1997) remind us, we cannot wait for seniors to raise questions about HIV/AIDS themselves, particularly when they do not know much about infection; feel they are not susceptible to infection (Rodgers, 1998, 1999); and do not feel infection could have a serious impact on their lives. To this end, Rose (1996) evaluated an HIV/AIDS education program based explicitly on the HBM model. The program involved 458 adults aged 60 and over residing at senior citizen centres. Pre-program knowledge, beliefs, and behaviours were determined by in-depth surveys. The education program included case-study presentations of seniors with HIV/AIDS and aimed to dispel myths identified in the initial survey. Post-program testing based upon questions from the initial survey showed increases in perceived susceptibility of infection; perceived severity of infection; total knowledge of HIV/AIDS; and understanding of the benefits of preventive sexual behaviours.
Strombeck and Levy (1998) reported on a prevention program launched in six regional senior citizens centres throughout Chicago. The program involved educating seniors with two-hour weekly sessions over four weeks. Videos, workbooks, and informal group discussions were used as part of the program. Results suggested increased HIV/AIDS knowledge and a decrease in myths about susceptibility and infection. Results also suggested an increase in the appreciation of the benefits of safer sexual practices. Under the HBM model, this achievement is critical because individuals will not engage in safer sexual practices if they perceive them to be ineffective in reducing HIV infection risk. As Rodgers-Farmer (1998, 1999) showed in her analysis of the AIDS Knowledge and Attitudes Supplement to the National Health Interview Survey, perceptions of the effectiveness of condom use were low among seniors aged 55 and up. Nurses and nurse practitioners can play a pivotal role in reinforcing for seniors beliefs in the effectiveness of these preventive behaviours (Wooten, 1999).
Another education program was initiated with senior women in Botswana—a country where HIV infection is significant and elder women are rarely the target of HIV/AIDS education (Tlou, 1996; see also Ingstad, Bruun, & Tlou, 1997). The program was designed to increase Tswanan elders' awareness of their HIV susceptibility and to empower them to take effective precautions. The program involved training several older women as trainers of other older women. Post-program evaluation suggested promise in raising awareness of HIV infection risk and preventive behaviours among both the elder trainers and their students. This is very encouraging because it has been shown that such modifying factors (Rosenstock, 1997) as minority racial status, poverty, and having fewer than 12 years of education are associated with lower levels of perceived susceptibility to HIV/AIDS infection (Rodgers-Farmer 1998, 1989; Brown & Sankar, 1998).
Consistent with the HBM model, the Tswana seniors program also emphasised self-efficacy by using a peer education model. Not only does peer education empower the trainers to believe that preventive sexual behaviours can be effective in HIV transmission, but their students are more likely to engage in safer sexual practices when they see that other women who share their same culture and life experiences are able to understand, demonstrate, and perform preventive behaviours themselves (see also Yates, Stellato, Johannes, & Avis, 1999).
Similar peer-education models are showing success for older gay men (Lieberman, 2000) and other senior populations at high risk for HIV infection. As stated above, the HBM model proposes that individuals will choose to engage in health behaviours if they perceive there to be few significant costs—'barriers'—to engaging in them. Peer education programs for gay men are showing effectiveness in behaviour change partly because they take into account the severe social stigma experienced by this group. As Anderson writes, "for the older gay man of today. . .the years of early socialization were a time of extreme condemnation from the church, medicine, psychiatry, the military, and the law" (Anderson, 1996, p. 66). Older gay men have spent a lifetime hiding their sexuality (Solomon, 1996); thus, they are unwilling to talk about safe sex practices with their doctors. Peer education programs for older gay men minimise this barrier to action by giving them an opportunity to learn about safer sexual practices in a safe, open, respectful environment (Lieberman, 2000). It should be noted, however, that even peer education will not be very effective for the gay man who is very old and has several chronic, life-threatening conditions. He may feel that since he is "going to die anyway", it would not be worth giving up the pleasures derived from unprotected sex (Nokes, 1996).
Also consistent with the HBM model, the education programs which currently show the most promise all encourage teaching methods that help seniors build a sense of efficacy in their ability to perform the behaviours that are taught to them. Gluck and Rosenthal (1996, cited in Strombeck & Levy, 1998) found that the most successful programs have included small group discussions and interaction between educators and seniors. Such learning environments give seniors the ability to ask many questions and gives them the sense that they as individuals are greatly responsible for enacting safer sexual practices. Gluck and Rosenthal also found that successful programs developed the skills needed to actually start practicing the safer sexual behaviours. Examples of such skills include 'lifeskills' (critical thinking, problem solving, reasoning, and decision making) and communications skills (e.g., negotiating condom use with partners and asking about partners' sexual histories).
Finally, it should also be noted that the most successful education programs have also adopted the HBM's proposition that 'cues to action' are needed to give individuals a 'push' to start using their newly-learned behaviours. In a three-county prevention program for Florida seniors, HIV/AIDS education is provided through traditional senior citizen centers as well as non-traditional settings such as libraries, bookstores, and condominium associations. The director of this project sees sex education as "a marketing effort that requires constant repetition in a variety of settings" (C. Gargotta, personal communication, 1997, quoted in Strombeck & Levy, 1998).
One shortcoming of the Health Belief Model is that it does not take into account the effect that cognitive variables such as beliefs and attitudes have on behaviour. The Theory of Reasoned Action (Fishbein, 1975) addresses this weakness. It proposes that people are rational and that they consider their behaviours before engaging in them. In this model, a behaviour is the result of one's intentions. Intentions are determined by: 1. one's attitude towards the behaviour (i.e., whether it is believed to be 'good' or 'bad'); and 2. one's perception of social pressures to engage or not engage in the behaviour. Both attitude towards the behaviour and perceptions of social pressure are determined by a system of beliefs. The attitude is determined by one's 'behavioural belief'—the belief that the recommended behaviour will lead to certain outcomes and the evaluation of these outcomes. The perception of social pressures is determined by one's 'normative belief'—the belief that one's reference group thinks s/he should/not engage in the recommended behaviour and one's motivation to comply with that reference group. The attitude towards the behaviour and the perception of social pressures are actively weighed against one another to produce intention to perform the behaviour. The behaviour is then performed.
Although this model makes the questionable assumption that individuals usually act on their intentions, its strength for HIV/AIDS prevention is in understanding how beliefs and attitudes can promote risky sexual behaviours, even when a person perceives him/herself at significant risk for infection; perceives that the infection will have a significant effect on his/her life; perceives that the recommended sexual behaviours will reduce likelihood of infection; and does not perceive there to be significant costs in performing safer behaviours. Once they identify these attitudes and beliefs, health promoters can tailor their sexual education programs to try to change these beliefs and attitudes.
Beliefs and attitudes appear to play a significant role in the risky sexual behaviour of older gay men. These men may exhibit a particularly negative attitude towards safer sexual practices that they otherwise know to be effective in preventing HIV infection. An 'attitude' is a manner, disposition, or emotional feeling towards something (see Fishbein, 1975). This negative attitude is influenced by a unique belief system. Older gay men grew up at a time when all they had to fear from unprotected were easily treated sexually transmitted diseases (Anderson, 1996). For most of their lives, condoms have not been part of their sexual experiences. The effect of this has been two-fold. Not only have older gay men grown accustomed to unprotected sex, but some have come to negatively associate condom use with 'disease'—something they perceive as part of a younger, more promiscuous generation of gay men. As Anderson writes, "[a]lthough older gay men are quite knowledegable about HIV transmission and are concerned about the epidemic. . .many express the sentiments of a 67-year-old client who said, 'Our people don't use condoms'" (Anderson, 1996, p. 68).
The Theory of Reasoned Action would also suggest that safer sexual behaviour is a function of normative pressure from one's gay peers, including those who are sexually active. This normative pressure would be the result of subjective beliefs as to whether or not other gay men believed safer sexual practices should be performed (and to what extent one actually cares about this reference group's beliefs). Subjective norms for safer sexual behaviour are generally weaker for older gay men than younger gay men. There are two reasons for this. First, the gay reference group as a whole may hold the same attitudes towards older people as does the dominant heterosexual population—that is, "old people don't have sex" or "old people are too nice to have (risky) sex" (Solomon, 1996). Second, although older gay men still maintain fairly strong ties with the larger gay community around them, they do so less than do younger gay men (Van de Ven, Rodden, Crawford, & Kippax, 1997). Thus, they are less likely to be subject to normative pressure of the broader gay community to engage in safer sexual practices, such as wearing condoms.
Educational efforts can be tailored to try to change these behaviours and attitudes. In New York City, the group Senior Action in a Gay Environment (SAGE) has started an educational and support program for older gay men with HIV/AIDS (Anderson, 1996). This peer-led program is focussing on secondary prevention of HIV infection. Not only is it providing HIV-positive men with guidance on how to protect themselves from acquiring AIDS-related opportunistic infections and how to avoid infecting their partners, but it is also challenging older gay men's beliefs that HIV/AIDS is something "belonging to another generation". Furthermore, the supportive nature of the SAGE group allows older gay men to develop stronger ties with the gay community. These stronger ties increase the importance older gay men place on adhering to the group norms of practicing safer sexual behaviour.
SAGE and similar programs (Lieberman, 2000) also take into account that the more 'closeted' a gay man is, the less likely he is to have changed his attitudes to be more in line with today's more liberal acceptance of homosexuality. By extension, a 'closeted' homosexual senior is likely to have a negative attitude towards any education about safer sexual practices. He will thus not be amenable to traditional sex education programs. However, because SAGE and other gay men's groups are able to offer such men a safe—if not anonymous—environment in which to discuss their sexual behaviours, their negative attitudes towards safer sexual practices may not interfere with sex education as much as they might outside such an environment. More importantly, their participation in these supportive, educational programs can start creating a 'virtual spiral' in which their attitudes towards safer sexual behaviours become more positive. On the other hand, because many older, closeted gay men have established their identities, families, and careers, they may perceive that the cost of approaching such a group would far outweigh any potential benefits.
Finally, research on the Theory of Reasoned Action has shown that the more specifically attitudes and behaviours are defined, the greater the likelihood that there will be a correspondence between one's intentions to act and one's actual behaviours (Mullen, 1987, cited in Salazar, 1991). The implication here is that sexual education programs that attempt to alter general attitudes towards safer sexual behaviours will be less successful than education programs that focus more on altering attitudes towards very specific behaviours. For example, research published by the Centers for Disease Control (see Appendix "E") has found that it is more productive to teach individuals to "have a condom beside their nightstand" than to teach them to simply "use condoms". Attitudes about "having safe sex" are much harder to change than are attitudes about performing specific behaviours.
Controlling and reducing the growing HIV/AIDS pandemic is one of the biggest challenges both technological and developing countries face in the 21st century. HIV/AIDS affects everyone it touches. It is, indeed, a global problem. This paper has examined efforts being made to control the spread of HIV/AIDS in senior populations. It has recognised that this age group, far from being asexual, is engaging in regular sexual activity, and that like every other age group, it too remains highly susceptible to acquiring and spreading HIV. Indeed, the rate of new HIV/AIDS infection in this age group has risen at an unprecedented pace over the last two decades. As Riley, Ory, and Zablotsky write, "the place of older persons in the AIDS epidemic can no longer be overlooked" (p. 216, cited in Nokes, 1996). Research has demonstrated that this spread is due primarily to risky sexual behaviours that facilitate the spread of HIV/AIDS.
Interestingly—and fortunately for seniors and health promoters alike—the traditional method of education in sex and safer sexual practices is fairly effective for this age group. Such education-based programs have been successful because they have drawn on various facets of two useful theoretical models: the Health Belief Model and the Theory of Reasoned Action. The Health Belief Model can determine optimal sexual education material and the most effective teaching procedures. The Theory of Reasoned Action can demonstrate how beliefs and attitudes can affect sexual behaviour change. Education programs can then be tailored to attempt to change these beliefs and attitudes.
Despite the promise that current programs are showing, research is still lagging far behind the realities experienced by today's sexually active seniors. Healthcare providers have long ignored the reality that seniors do have sex and that they are at risk for HIV/AIDS. Thus, health promotion research has focussed disproportionately on prevention in younger populations. This has served to perpetuate the negative attitudes and stereotypes that encourage silence around the issue of elder sexuality—among both seniors and their healthcare providers. This has in turn frustrated any progress that can be made through sound sexual educational programs that are targeted to sexually active seniors.
Furthermore, current programs are only beginning to reach the many different subgroups of sexually active seniors. Current behaviour change models must be expanded in order to better understand, predict, and help change these individuals' sexual behaviours. High-risk groups, including older homosexual men; those who are poor; those who cannot read or write; and those with cognitive impairments require special programs that address their unique needs.
[1] The emphasis of this paper is on HIV infections that appear to have occurred in older age. This is to distinguish from infections that occurred when individuals were younger and are only in older age beginning to cause noticeable symptoms.
[2] There are two forms of HIV: HIV-1 and HIV-2. Reference is to HIV-1; HIV-2 is rare in North America.
[3] Although rarer, infection can also conceivably occur during oral sex in which infected semen, vaginal fluids, or blood enter open sores in the mouth. These sores can be caused by toothbrushing, dental flossing, or trauma caused by chewing hard foods. In many cases, such sores are invisible. Therefore, when there is a known risk of HIV infection, barrier devices should be used during oral sex (e.g., condoms during fellatio and dental dams during cunnilingus).
[4] These behaviours are particularly risky because they can easily tear the anus or the mucous membrane of the rectum, causing 1. sores through which HIV can enter, and 2. the discharge of infectious blood.
[5] It is recognised, of course, that successful HIV/AIDS prevention strategies must involve intervention at multiple levels (i.e., individual, healthcare system, government). The focus of this paper, however, is on the individual level.
American College of Physicians and Infectious Diseases Society of America. (1993). Human immunodeficiency virus (HIV) infection. Annals of Internal Medicine, 120, 310-319.
Anderson, G. (1996). The older gay man. In K.M. Nokes (Ed.), HIV/AIDS and the older adult. Washington, DC: Taylor & Francis.
Ankrom, M., & Greenough, W.B. III. (1997). Delayed diagnosis: A 78-year-old man with AIDS. Journal of the American Geriatrics Society, 45 (10), 1282-1283.
Bachus, M.A. (1998). HIV and the older adult. Journal of Gerontological Nursing, 24 (11), 41-46.
Barlow, D.H., & Durand, V.M. (1995). Sexual and gender identity disorders. In D.H. Barlow & V.M. Durand (Eds.), Abnormal psychology. Pacific Grove, CA: Brooks/Cole.
Bausell, R. (1986). Health seeking behavior among the elderly. The Gerontologist, 26 (5), 556-558.
Brown, D.R., & Sankar, A. (1998). HIV/AIDS and aging minority populations. Research on Aging, 20 (6), 865-884.
Bulcroft, R., & Bulcroft, K. (1991). The nature and functions of dating in later life. Research on Aging, 13 (2), 244-260.
Burbank, P.A., Padula, C.A., & Nigg, C.R. (2000). Changing health behaviors of older adults. Journalf of Gerontological Nursing, 26 (3), 26-33.
Catania, J.A., Turner, H., Kegeles, S.M., Stall, R., & Pollack, L. (1989). Older Americans and AIDS: Transmission risks and primary prevention research needs. Gerontologist, 29 (3), 373-381.
Center for Women Policy Studies. (1994). Midlife & older women and HIV/AIDS. Washington, DC: American Association of Retired Persons.
Centers for Disease Control and Prevention. (1991). Perspective: Changing outlooks. HIV/AIDS Surveillance Report, 2 (3), 1-2.
Centers for Disease Control and Prevention. (1993). U.S. AIDS cases through September 1993. HIV/AIDS Surveillance Report, 5 (3).
Centers for Disease Control and Prevention. (1995). HIV/AIDS cases through September 1993. HIV/AIDS Surveillance Report, 6 (2).
Centers for Disease Control and Prevention (2001). Revised guidelines for HIV
counseling, testing, and referral. Morbidity and Mortality Weekly Reports, 50
(RR-19), 1-58.
Available: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5019a1.htm
El-Sadr, W., & Gettler, J. (1995). Unrecognized human immunodeficiency virus infection in the elderly. Archives of Internal Medicine, 155 (2), 184-186.
Feldman, M.D. (1994). Sex, AIDS, and the elderly. Archives of Internal Medicine, 154 (1), 19-20.
Fishbein, M., & Azjen, I. (1975). Beliefs, attitudes, intentions and behavior. Boston: Addison-Wesley.
Gaeta, T.J., LaPolla, C., & Melendez. E. (1996). AIDS in the elderly: New York City vital statistics. Journal of Emergency Medicine, 14 (1), 19-23.
Gordon, S.M., & Thompson, S. (1995). The changing epidemiology of human immunodeficiency virus infection in older persons. Journal of the American Geriatrics Society, 43 (1), 7-9.
Grossman, A.H. (1995). At risk, infected, and invisible: older gay men and HIV/AIDS. Association of Nurses in AIDS Care Journal, 6 (6), 13-19.
Hillman, J.L., & Stricker, G. (1999). Some issues in the assessment of HIV among older adult patients. Psychotherapy: Theory, Research, Practice, Training, 35 (4), 483-489.
Ingstad, B., Bruun, F.J., & Tlou, S. (1997). AIDS and the elderly Tswana: The concept of pollution and consequences for AIDS prevention. Journal of Cross Cultural Gerontology, 12 (4), 357-372.
Kinsey, A.C., Pomeroy, W.B., & Martin, C.E. (1948). Sexual behavior in the human male. Philadelphia: Saunders.
Kinsey, A.C., Pomeroy, W.B., Martin, C.E., & Gebhard, P.H. (1953). Sexual behavior in the human female. Philadelphia: Saunders
Levy, J.A. (1988). AIDS and injecting drug use in later life. Research on Aging, 20 (6), 776-797.
Lieberman, R. (2000). HIV in older Americans: An epidemiologic perspective. Journal of Midwifery and Women's Health, 45 (2). 176-182.
Linsk, N.L. (2000). HIV among older adults: age-specific issues in prevention and treatment. AIDS Reader, 10 (7), 430-40.
Mack, K.A., & Bland, S.D. (1999). HIV testing behaviors and attitudes regarding HIV/AIDS of adults aged 50-64. Gerontologist, 39 (6), 687-694.
McCaig, L., Hardy, A., & Winn, D. (1991). Knowledge about AIDS and HIV in the US adult population: Influence of the local incidence of AIDS. American Journal of Public Health, 81, 1591-1595.
Nocera, R. (1997). AIDS and the older person. Topics in Geriatric Rehabilitation, 12 (4), 72-85.
Nokes, K.M. (1996). Health care needs. In, K.M. Nokes (Ed.), HIV/AIDS and the older adult. Washington, DC: Taylor & Francis.
Nokes, K.M. (1996). Preface. In, K.M. Nokes (Ed.), HIV/AIDS and the older adult. Washington, DC: Taylor & Francis.
Ory, M.G., & Mack, K.A. (1998). Middle-aged and older people with AIDS. Research on Aging, 20 (6), 653-664.
Puleo, J.H. (1996). Scope of the challenge. In K.M. Nokes (Ed.), HIV/AIDS and the older adult. Washington, DC: Taylor & Francis.
Rodgers-Farmer, A.Y. (1999). HIV risk factors, HIV antibody testing, and AIDS knowledge among African Americans age 55 years and older. Social Work in Health Care, 29 (3), 1-17.
Rodgers-Farmer, A.Y. (1998). HIV risk factors, HIV antibody testing, and AIDS knowledge among older Americans. Journal of Gerontological Social Work, 30 (3-4), 133-146.
Rose, M.A. (1996). Effect of an AIDS education program for older adults. Journal of Community Health Nursing, 13 (3), 141-148.
Rosenstock, I.M. (1997). The health belief model: Explaining health behavior through expectancies. In, K. Glanz, F.M. Lewis, & B.K. Rimer (Eds.), Health behavior and health education: Theory, research, and practice. (2nd Edition). San Francisco: Jossey-Bass.
Salazar, M.K. (1991). Comparison of four behevioral theories: A literature review. American Association of Occupational Health Nurses, 39 (3), 128-135.
Schable, B., Chu, S.Y., & Diaz, T. (1996). Characteristics of women 50 years of age or older with heterosexually acquired AIDS. American Journal of Public Health, 86 (11), 1616-1618.
Schlesinger, B. (1996). The sexless years or sex rediscovered. Journal of Gerontological Social Work, 26 (1/2), 117-131.
Siegal, D.L., & Burke, C. (1997). Midlife and older women and HIV/AIDS: My (grand)mother wouldn't do that. In Nancy Goldstein and Jennifer L. Manlowe (Eds.), Gender politics of HIV/AIDS in women: Perspectives on the pandemic in the United States. New York: New York University Press.
Skiest, D.J., & Keiser, P. (1997). Human immunodeficiency virus infection in patients older than 50 years: A survey of primary care physicians' beliefs, practices, and knowledge. Archives of Family Medicine, 6 (3), 289-294.
Solomon, K. (1996). Psychosocial issues. In K.M. Nokes (Ed.), HIV/AIDS and the older adult. Washington, DC: Taylor & Francis.
Speer, D.C., Kennedy, M., Watson, M., Meah, J., Nichols, J., & Watson, B. (1999). Ethnic, demographic, and social differences among middle and older adults with HIV/AIDS. AIDS Patients Care and Stds, 13 (10), 615-624.
Stall, R., & Catania, J. (1994). AIDS risk behaviors among late middle-aged and elderly Americans: The National AIDS Behavioral Surveys. Archives of Internal Medicine, 154 (1), 57-63.
Strombeck, R., & Levy, J.A. (1998). Educational strategies and interventions targeting adults age 50 and older for HIV/AIDS prevention. Research on Aging, 20 (6), 912-936.
Szirony, T.A. (1999). Infection with HIV in the elderly population. Journal of Gerontological Nursing, 25 (1), 25-31.
Talashek, M.R., Tichy, A.N., & Epping, H. (1990). Sexually transmitted diseases in the elderly: Issues and recommendations. Journal of Gerontological Nursing, 16 (4), 33-40.
Tlou, S. (1996). Empowering older women in AIDS prevention: The case of Botswana. South African Journal of Gerontology, 5 (2), 27-32.
Van de Ven, P., Rodden, P., Crawford, J., & Kippax, S. (1997). Comparative demographic and sexual profile of older homosexually active men. Journal of Sex Research, 34 (4), 349-360.
Whipple, B., & Scura, K.W. (1996). Overlooked epidemic: HIV in older adults. American Journal of Nursing, 96 (2), 23-29.
Wiley, D. & Bortz, W.M.II. (1996). Sexuality and ageing-usual and successful. The Journals of Gerontology, 51, 142-150
Wooten, B.K. (1999). HIV and AIDS in older adults. Geriatric Nursing, 20 (5), 268-272.
Wright, S.D., Drost, M., Caserta, M.S., & Lund, D. (1998). Older adults and HIV/AIDS: Implications for educators. Gerontology and Geriatrics Education, 18 (4), 3-21.
Yates, M.E., Stellato, R.K., Johannes, C.B., & Avis, N.E. (1999). Importance of AIDS-related knowledge for mid-life and older women. AIDS Education and Prevention, 11 (3), 224-231.
Zablotsky, D.L. (1998). Overlooked, ignored, and forgotten: Older women at risk for HIV infection and AIDS. Research on Aging, 20 (6), 760-775.
Zelenetz, P.D., & Epstein, M.E. (1998). HIV in the elderly. AIDS Patient Care
and STDs, 12 (4), 255-262.
* Includes only persons reported with HIV infection who have not developed AIDS
From: Centers for Disease Control and Prevention
(2000). U.S. HIV and AIDS cases reported through December 2000 (Year End Edition). HIV/AIDS
Surveillance Report, 12 (2). Available: http://www.cdc.gov/hiv/stats/hasr1202.htm
From: Centers for Disease Control and Prevention
(2001). HIV and AIDS-United States, 1981-2000. Morbidity and Mortality Weekly Reports
50 (21), 430-434. Available: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5021a2.htm
| Disease | Presumptive criteria |
| Candidiasis of esophagus | Recent onset of retrosternal pain on swallowing; AND Oral candidiasis diagnosed by the gross appearance of white patches or plaques on an erythematous base or by the microscopic appearance of fungal mycelial filaments from a non-cultured specimen scraped from the oral mucosa. |
| Cytomegalovirus retinitis | A characteristic appearance on serial ophthalmo-scopic
examinations (e.g., discrete patches of retinal whitening with distinct borders, spreading
in a centrifugal manner along the paths of blood vessels, progressing over several months,
and frequently associated with retinal vasculitis, hemorrhage, and necrosis). Resolution
of active disease leaves retinal scarring and atrophy with retinal pigment epithelial
mottling. Mycobacteriosis microscopy of a specimen from stool or normally sterile body fluids or tissue from a site other than lungs, skin, or cervical or hilar lymph nodes that shows acid-fast bacilli of a species not identified by culture. |
| Kaposi's sarcoma | A characteristic gross appearance of an erythematous or violaceous plaque-like lesion on skin or mucous membrane. (Note: Presumptive diagnosis of Kaposi's sarcoma should not be made by clinicians who have seen few cases of it.) |
| Pneumocystis carinii pneumonia | A history of dyspnea on exertion or nonproductive cough of
recent onset (within the past 3 months); AND Chest x-ray evidence of diffuse bilateral interstitial infiltrates or evidence by
gallium scan of diffuse bilateral pulmonary disease; AND Arterial blood gas analysis showing an arterial pO((2)) of less than 70 mm Hg or a low
respiratory diffusing capacity (less than 80% of predicted values) or an increase in the
alveolar-arterial oxygen tension gradient; AND No evidence of a bacterial pneumonia. |
| Pneumonia, recurrent | Recurrent (more than one episode in a 1-year period), acute (new symptoms, signs, or x-ray evidence not present earlier) pneumonia diagnosed on clinical or radiologic grounds by the patient's physician. |
| Toxoplasmosis of brain | Recent onset of a focal neurologic abnormality consistent
with intracranial disease or a reduced level of consciousness; AND Evidence by brain imaging (computed tomography or nuclear magnetic resonance) of a
lesion having a mass effect or the radiographic appearance of which is enhanced by
injection of contrast medium; AND Serum antibody to toxoplasmosis or successful response to therapy for toxoplasmosis. |
| Tuberculosis, pulmonary | When bacteriologic confirmation is not available, other reports may be considered to be verified cases of pulmonary tuberculosis if the criteria of the Division of Tuberculosis Elimination, National Center for Prevention Services, CDC, are used. The criteria in use as of January 1, 1993, are available in MMWR 1990;39(No. RR-13):39- 40. |
Taken from: Centers for Disease Control and
Prevention (1993). 1993 revised classification system for HIV infection and expanded
surveillance case definition for AIDS among adolescents and adults. Morbidity and
Mortality Weekly Reports, 41 (RR-17). Available: http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/00018871.htm
| Primary Prevention | Secondary Prevention | Tertiary Prevention |
| Provide safe sex education. | Obtain sexual histories to identify at-risk individuals. | Provide emotional support for all clients and their families. |
| Provide individual counselling for those at risk. | Identify all causative organisms, even if treating on presumptive diagnosis. | |
| Encourage community-based education programs. | Treat following 1985 CDC recommendations. | Identify clients with emotional sequelae and refer for evaluation and treatment. |
| Institute community programs using the media or group presentations. | Treatment protocols should include test of cure. | Provide care for those with neurological sequelae from syphilis. |
| Screen blood products nationally. | Educate clients to enhance compliance with treatment, including sexual abstinence until test of cure, and keeping appointments. | |
| Avoid unnecessary transfusions. | Elicit, trace, screen, and treat contacts. | |
| Encourage latex condom use. | Report all reportable diseases. | |
| Guard against self-contamination. | Make treatment available in a timely, cost-effective manner. | |
| Support legislation mandating research. |
Adapted from: Talashek, M.R., Tichy, A.N., &
Epping, H. (1990). Sexually transmitted diseases in the elderly: Issues and
recommendations. Journal of Gerontological Nursing, 16 (4), 33-40. (p. 38).
| Global risk reduction steps, which are unlikely to be effective in changing behaviour | Specific risk reduction steps, which are more likely to be effective in changing behaviour |
| Always use condoms. | Buy a condom tomorrow and try it on. Carry a condom next time I go out (on a date, etc.) Starting today, put condoms on the nightstand beside the bed. Starting tonight, require my partner to use a condom next time, or I will not have vaginal (anal) sex. |
| Have fewer or less risky partners. | Stop seeing (specific partner) who is seeing other people. Break up with (specific partner) before getting together with someone new. |
| Have safer sex. | Talk honestly with (specific partner) about my HIV status and
ask about his/her HIV status. Next time I'm out (on a date, etc.) and may have sex, avoid getting 'high' on drugs
and/or alcohol. Only kissing, etc., with (specific partner) until we both have an HIV test. Tomorrow, ask (specific partner) if he or she has had a recent HIV test and has been tested for other sexually transmitted diseases. |
| Stop injecting drugs. | Obtain clean works (i.e., needles, syringes, cottons, or
cookers*) tomorrow so I have them before I use next time. Contact drug treatment centre and make appointment. |
* Cottons are filters used to draw up the drug solution. Cookers include
bottle caps, spoons, or other containers used to dissolve drugs.
From: Centers for Disease Control and Prevention
(2001). Revised guidelines for HIV counseling, testing, and referral: Technical expert
panel review of CDC HIV Counseling, Testing, and Referral Guidelines. Morbidity and
Mortality Weekly Reports, 50 (RR-19),1-58. Available: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5019a1.htm
Copyright © 2001, by Eddy M. Elmer
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