For persons over 50 years of age, many of the risk factors for HIV infection are the same as those for younger persons.

Sexual Risk Factors

Many older adults are sexually active and thus are as vulnerable as younger persons to acquiring HIV through sexual transmission. A recent survey of sexual behavior among older adults showed that 73% of persons aged 57–64 had had sex during the past year, as had 53% of those aged 65–74 and 26% of those aged 75–85 [3].

Older persons who are infected with HIV can spread the disease to their sex partners. Older persons who are not infected, especially those resuming sexual relations after a divorce or the death of a partner, may not perceive themselves as at risk for HIV and may not take preventive measures such as using condoms or getting tested for HIV. Like younger persons, older persons need to know their own HIV serostatus and that of potential sex partners.

Older women may be especially at risk for HIV infection because age-related vaginal thinning and dryness can lead to tears in the vaginal area [4]. Older women who become sexually active with new partners after many years in a monogamous relationship may find it awkward to initiate discussions about potential risks and preventive measures such as using a condom.

Drug Use

Some older persons inject drugs or smoke crack cocaine, which can put them at risk for HIV infection. HIV transmission through injection drug use accounts for more than 16% of AIDS cases among persons aged 50 and older [5]. In one study [6], although drug users 50 years and older were less likely than a younger cohort to share needles, they were just as likely as younger drug users to engage in risky sexual behavior. The researchers also found that older users who smoked crack engaged in behaviors that were deemed extremely risky (for example, injecting drugs, having multiple sex partners, and exchanging sex for drugs or money). Older injection drug users living with HIV tend to be poorer and to have less social support than their younger counterparts [7].

Lack of Knowledge about HIV/AIDS

Some older persons, compared with those who are younger, may be less knowledgeable about HIV/AIDS and therefore less likely to protect themselves. Many do not perceive themselves as at risk for HIV, do not use condoms, and do not get tested for HIV.

• In one study, almost 60% of older single women who had been sexually active during the past 10 years had engaged in sex without a condom [8].
• More than half of older rural African American women in another study had at least one risk factor for HIV infection, such as engaging in sex without a condom [9].
• In several studies, researchers have found that older persons had misconceptions about HIV risks, such as believing that the virus can be transmitted only by blood transfusions or casual contact [10].
• Only 13% of older women in one study said that condoms were effective prevention [11].

Being a Member of a Minority Race/Ethnicity

Older persons of minority races/ethnicities may face specific prevention challenges. For example, in one study, older black and Latino men who have sex with men were at elevated risk of acquiring HIV because they were sexually active, had multiple partners, and included drug use in their sexual activity [12]. Moreover, older men who are not white tend to receive an HIV diagnosis later than their white counterparts do, thus delaying treatment and increasing the opportunity for further HIV transmission [13].

Stigma may be a greater issue for older persons of minority races/ethnicities. For example, in one study, most elderly HIV-positive African Americans said that their age was a major barrier to seeking service and family support [14].

Underestimation of Risk by Health Professionals

Health care professionals may not consider discussing HIV/AIDS with older patients and thus may miss opportunities to deliver prevention messages, offer HIV testing, or make an early diagnosis that could help their patients get early care. Physicians and nurses may be influenced by the stereotype that older patients are not sexually active or do not use drugs, so they may not ask about those risk behaviors. Health professionals also may be uncomfortable about raising these issues with patients who are older than they are. In a recent study of sexuality among older persons, only 38% of men and 22% of women said that they had discussed sex with their doctor since age 50 [3].

Misdiagnosis

AIDS may not be diagnosed because some symptoms can mimic those of normal aging, for example, fatigue, weight loss, and mental confusion. Early diagnosis, which typically leads to the prescription of HAART and to other medical and social services, can improve a person's chances of living a longer and healthier life. According to a recent study [15], HAART benefits older persons as much as it does younger persons. However, because older persons tend to receive diagnosis later (after aging has affected the immune system), their immunological response may be less than that of younger persons.

Older HIV-infected persons, even those who are living longer because of HAART, may begin to develop other chronic health conditions related to aging, such as hypertension, diabetes, and Alzheimer's disease. HAART can affect, and possibly worsen, these medical conditions [16]. Further, the decreased immune function that results from aging makes older persons more vulnerable to a rapid progression of HIV infection to AIDS.

Stigma

The stigma of HIV/AIDS may be more severe among older persons, leading them to hide their diagnosis from family and friends. Failing to disclose that they are infected limits or precludes potential emotional and practical support [17].

Conclusion

In the world of HIV prevention, persons over the age of 50 have been called the invisible population. Few prevention campaigns have focused their messages on older adults and their concerns. Moreover, few clinical trials of drug efficacy and safety have included older persons, and persons aged 50 and older have been excluded from most sexually transmitted disease risk-reduction trials [18]. Because more persons are living longer in good health, those over the age of 50 could benefit from HIV prevention efforts.