Study looks at unmet needs for HIV prevention among older adults in sub-Saharan Africa

One of the most common myths around older adults is that they are not sexually active. But a recent study conducted by researchers at Indiana University found that older men and women do maintain sexual relationships even into their 80s and beyond. Since older adults are often ignored in sexual health education, the possibility for HIV transmission is heightened.

The study, conducted by Molly Rosenberg, assistant professor of epidemiology and biostatics in the IU School of Public Health-Bloomington, was recently published in the Journal of Acquired Immune Deficiency Syndromes. It looked at the unmet needs for HIV prevention among older adults in sub-Saharan Africa, one of the first studies of its kind to report sexual risk-taking among older adults in that region.

"Our study found that older adults are sexually active, and they report sexual risk behaviors -- low condom use, casual sex and multiple recent partners -- that are consistent with sexual transmission of disease," Rosenberg said. "This marks a huge potential for ongoing HIV transmission in older South Africans, and highlights the need for expanded HIV testing and counseling that can change behavior and help reduce new HIV transmission."

Researchers analyzed data from 5,059 men and women age 40 and older from the study "Health and Aging in Africa: Longitudinal Studies of INDEPTH Communities," conducted in rural Mpumalanga province in South Africa. Of those enrolled, 46 percent were men, 51 percent were currently married, and 46 percent had no formal education. The research looked at HIV prevalence, described their sexual behaviors and compared those behaviors across HIV status categories, using both self-reported and laboratory-confirmed HIV status data.

Older adults receive little attention when it comes to HIV prevention research and interventions, although growing evidence shows they make up a fast-increasing proportion of people living with HIV, in part because of the impact of large-scale HIV treatment on reducing deaths from the disease. Research on the group remains scarce, however, especially in sub-Saharan Africa, where most of the world's 37 million people infected with HIV live, and prevention measures focus mostly on younger adults.

"This is really the first generation of South Africans we've seen aging with HIV," Rosenberg said.

Overall, HIV prevalence among people in the study was high, at 23 percent, and did not differ between men and women. About one-third of respondents reported never having been tested for HIV, and among those with confirmed infections, nearly half did not yet know they were living with HIV.

Regarding sexual activity, more than half of participants reported at least one sex partner within the past two years. Men tended to maintain sexual partnerships at relatively high rates across older ages, only dropping to 52 percent at age 80 and older. The proportion of women with recent sexual partners decreased more steeply with age, dropping to 6 percent at age 80 and older.

Individuals who reported condom use decreased with age in both men and women, as did those reporting casual or anonymous sex. Condom use was highest, at 75 percent, among those who were HIV positive, but only if they knew their status. Of those who were HIV positive but unaware of their status, only 27 percent regularly used condoms.

One in 10 participants also reported that their most recent sex partners were casual or anonymous. Casual sex was lowest among HIV-negative adults, at 9 percent, and higher among both HIV-positive groups (29 percent of those aware of their HIV status and 18 percent of those who were unaware). The results, Rosenberg said, show not only a commonality among sexually active young people and older people, but also the need for targeted intervention among older adults.

The study calls for inclusion of older adults in HIV prevention, with messages created directly for that demographic, and intensified counseling and motivation about sexual transmission risk and universal HIV testing.

"To control the HIV epidemic in South Africa, we need to reach everyone who is vulnerable to HIV," Rosenberg said. "And our paper shows that older adults should clearly be considered as HIV-vulnerable."