The Aging Face of AIDS
Experts foresee an ominous trend in risky behaviors among elders.
By Leslie Laurence and Lani Luciano
One thing you won't spot in the gauzy, romantic ads for Viagra is a warning about AIDS. "Older people just don't think about safer sex," notes Judith Levy, Ph.D., associate professor of health policy and administration at the University of Illinois. Besides, she adds, "it's a challenge to put a condom on an already challenged organ." Only 11% of all U.S. HIV/AIDS cases reported to the Centers for Disease Control and Prevention (CDC) have been in people 50 and over, but in recent years the disease has risen twice as fast in this age group compared with younger adults. "The future of the epidemic really is in older people," observes Amy Justice, M.D., Ph.D., assistant professor of medicine at the University of Pittsburgh. At least half of all new HIV infections are in people under age 25. Yet experts are bracing for an age wave, thanks in part to life-prolonging treatments for the virus -- and an ominous factor as well: namely that people over 50 may be more exposed to infection than many health professionals or even elders themselves realize. Among the underestimated perils: sexual risk-taking (facilitated by the new remedy for erectile dysfunction), the biological vulnerabilities of advancing age and even the sharing of hypodermic needles. Many physicians don't regard their older patients as sexually active (one Texas study found that 40% rarely or never mention HIV to them), but the data show otherwise. The CDC reports that the percentage of HIV/AIDS cases traced to heterosexual contact among those over-50 is comparable to that in the younger population and, according to sex education experts, reticence and ignorance may be heightening older people's risk. "This is a generation that didn't necessarily grow up thinking or talking about condoms," explains Monica Rodriguez, director of information and education at the Sexuality Information and Education Council of the United States (SIECUS). "And most women over 50 aren't concerned about pregnancy, either." Jane Fowler, co-founder of the National Association on HIV Over 50, cites one such example, her own. In 1985, after her divorce, she fell into a comforting relationship with a longtime friend who was also divorced. Five years later, at age 50, Fowler learned she was HIV-positive. "My first reaction was, how could this happen to me?" she recalls. "I was the perfect 50s girl -- a virgin on my wedding day and faithful for 23 years of marriage. It hadn't occurred to me I'd put myself at risk by engaging in unprotected sex with a close friend." The aging process itself seems to increase women's susceptibility to infection. Studies show that all women are at higher risk of vaginal sex transmission than men but older women are more vulnerable than younger ones, possibly due to thinning vaginal walls and abrasions resulting from insufficient lubrication. Yet, doctors often assume hot flashes, night sweats and depression are symptoms of menopause so diagnosis is often delayed and patients progress more rapidly to full-blown AIDS. Diane Zablotsky, Ph.D., associate professor of sociology at the University of North Carolina at Charlotte, faults health professionals for dismissing or avoiding the sex lives of their older patients. "We've not asked pointed questions such as: How comfortable are you using condoms? Do you know how to put one on?" In fact, says Zablotsky, doctors may be reticent themselves: "'She's 55 and recently widowed. I can't ask about her sex life.' Well, you'd better." Their own monogamy may offer little protection for older women since men, who according to the CDC account for more than 80% of AIDS patients over 50, may have multiple partners. "Down here, there are seven women to every man," explains John Gargotta, supervisor of the Senior HIV Intervention Program (SHIP) in Florida's Broward, Dade and Palm Beach counties, where people over 50 constitute 15% of newly-diagnosed cases. "People lose their partner, they get lonely but they just don't think of AIDS as their disease," says Gargotta. "Some men visit prostitutes or gay bars, then bring the disease back to their girlfriend in the condo." Perhaps the most surprising infection risk among older people is the sharing of needles used for insulin or illicit drugs. Although there are no hard data on either of these practices, John Gargotta says that sharing insulin syringes is not uncommon in the congregate living communities of south Florida. "Some people need to save a few bucks if they can." As for illicit drugs, before 1988, the CDC reported virtually no HIV infections traced to drug use in people over age 50. Today, the agency says, it accounts for 17% of infections. Though most of this population is assumed to be long-term addicts, researchers are just beginning to study late-onset drug users. Says Isaac Montoya, Ph.D., senior research scientist at Affiliated Systems Corporation, a Houston health care think tank, "Older people are often bored and they have the (money) to engage in experimental drug use. We don't know exactly how they get hooked, but it appears that they do progress to IV drugs." Montoya, who is seeking a grant from the National Institutes of Health to investigate late-onset drug use among older people, cautions that so far the evidence is anecdotal. However, he says, based on interviews he and colleagues have conducted, a picture is beginning to emerge. One danger: "snowbirding" -- retiree transits between warm spots. "Older people stay in these huge RV parks, fostering a lot of socialization that can lead to high-risk behaviors such as drug use or exchanging sexual partners." Others use illicit drugs to self-medicate for loneliness, says Montoya. They start with cocaine, which alters their judgment, and eventually progress to IV drugs, reasoning, "I'm old. I don't have much time to live anyway. What's the difference if I die from HIV or in a car crash or from an overdose." Tackling these deep-rooted behaviors, says Montoya, won't be easy. "It's sad that none of us had the foresight to jump on this earlier." It's not just residents of Southern retirement enclaves who have researchers worried. "Crack used to be a young man's drug," says Wendell Johnson, Ph.D, assistant professor of family and preventive medicine at Atlanta's Emory University. For the past year, Johnson has been studying older African-American men with no prior drug history who buy crack cocaine for younger women in exchange for sex. "Sometimes they decide to try it themselves and they like the sexual energy it gives them." But whether or not the men get hooked, says Johnson, the resulting drug-focused relationships are uncommitted and, thus, risky. "I think we're dealing with just the tip of the iceberg," warns Judy Fink, a senior program specialist with AARP. "We've got more and more folks out there who were previously unable to have sex and now Viagra comes along and it's wonderful." To alert older people to the risks of HIV transmission, AARP is distributing a video entitled "HIV/AIDS: It Can Happen to Me" to health care providers, senior centers and AIDS organizations ($20, AARP Program Scheduling Office, 601 E. Street, N.W., Washington, D.C. 20049, 202-434-6023). Marcia Ory, Ph.D., chief of Social Science Research on Aging at the National Institute on Aging, agrees with Fink that the issue is just emerging but she says public health agencies have no time to waste. "We have a rare opportunity to see an epidemic move along gradually and try to do something about it," she says. "While we don't want to go out and scare older people, we've got to make sure they get the message. If they're sharing needles and having sex with a partner they don't know, they're at the same risk as a 25-year-old."
Leslie Laurence is a National Magazine Award-winning journalist specializing in women's health and health policy. Her work has appeared in Glamour, Town & Country, New York, Redbook and many other magazines. Lani Luciano is a freelance editor specializing in health policy and health economics. She has been a commentator on public radio's "Marketplace" and her work has appeared in Barron's, Money, Business and Health and other magazines. This is part of the KHN Morning Briefing, a summary of health policy coverage from major news organizations. Sign up for an email subscription.