We will be looking at the risk associated with contracting HIV as an older person, alongside some of the reasons why this age group may not be accessing testing services as frequently as other age groups.
It is a commonly believed misconception that HIV only affects men who have sex with men (MSM), people with ‘promiscuous’ sexual lifestyles, young people, people of particular descent, or people who inject drugs. However, HIV can be contracted by anyone, no matter their sexuality, gender, ethnicity, lifestyle choices, or age. This blog post will focus specifically on the importance of people over 50 getting tested for HIV.
Why is it important for people over the age of 50 to test for HIV?
HIV testing most commonly involves taking a small blood or saliva sample and testing it for the virus. These tests are free on the NHS in the UK and often completed in sexual health clinics, community centres, and home testing kits It can take from three to six months for signs of the virus to show up in your blood, so it is important to test straight away after your last potential exposure, and follow up again with another test three months later.
Despite a decline in the number of new HIV infections in the UK overall, the number and proportion of new HIV diagnoses in people aged 50+ years continues to increase. In fact, In England, older adults (aged ≥50 years) are at greater risk of being diagnosed with advanced stage HIV infection than younger adults. Furthermore, many infections among the 50+ population were actually acquired at age 50+ (i.e., HIV was contracted when the person was over 50, rather than when they were younger) (BMC Public Health, 2018).
There are some sexual and relationship difference in older age which may put older people at increased risk of HIV. Vagnial dryness in older women can cause increased risk of contracting HIV, and lack of concern about pregnancy can mean that older people are less likely to use HIV-prevention methods such as condoms (HIV Info, 2021). Furthermore, early stage HIV often presents itself in the form of a cold or flu, so many older people may just mistake HIV for other age-related symptoms (BMC Public Health, 2018).
People aged ≥50 years are disproportionately affected by late diagnosis, which is associated with poorer health outcomes, increased treatment complexity and increased healthcare costs. It is also important to note that many older people living with HIV are at higher risk of dementia, diabetes, osteoporosis and frailty, due to the effect that the virus has on the immune system (THT, 2024). Many older women can have their symptoms of menopause exacerbated by HIV, and some HIV drugs can have an effect on HRT treatment (AIDSMap, 2021). Finally, many older people are affected by age-related changes to their ability to think or remember, which may reduce their ability to stick to a consistent drug regime (HIV Info, 2021).
However, getting diagnosed with HIV in the 2020s is completely different to getting a diagnosis in the 1980s, as HIV treatment has become much more effective and reliable. While there's no cure for HIV, there are very effective treatments that enable most people with the virus to live a long and healthy life (NHS, 2024). Usually, people who have just been diagnosed with HIV take between 1 and 4 pills a day, and this reduces their viral load of HIV down to an ‘undetectable’ level – meaning that even if you have unprotected sex, as long as you are taking medication consistently, you CANNOT pass on the HIV infection (NHS, 2024).
Why do people over the age of 50 tend not to get tested for HIV?
Many people over the age of 50 have never gotten an HIV test, and thus are unaware of their HIV status. Below, we will highlight five main reasons why people over the age of 50 do not get tested for HIV, as identified in the BMC Public Health research article.
Reason 1: Risk Perception/Stigma ‘I can’t get HIV, I’m not gay!’
People who tested positive for HIV over the age of 50 stated that they previously believed it was impossible for them to contract HIV. Many believed that HIV was a disease that affected young people, so they did not believe that they were at risk themselves. A majority of this age group viewed the distressing adverts throughout the 80s and 90s regarding HIV and AIDs, and held onto many of the myths that existed throughout these campaigns. These myths indicated that HIV was only transmissable between people who were ‘promiscuous, gay, African, or drug users’(BMC Public Health, 2018).
Furthermore, this group stated they believed their partners were ‘clean’ and ‘nice’ and so they felt that they did not have any risk. Finally, they stated that they believed they ‘should know better’ than to engage in sex with multiple partners, and felt shame if they had done so, highlighting the stigma attached to older people and sexuality (BMC Public Health, 2018).
Advertising campaigns that solely target young people or MSM are clearly excluding and alienating older populations from the reality of HIV infection and transmission. It is important to stress during outreach and advertising campaigns, that anyone is at risk of contracting HIV at some point in their lives, regardless of their gender, sexuality, age group, or lifestyle choices.
Reason 2: Symptom Mis-Attribution
The symptoms of early-stage HIV in older people may be mistaken for other illnesses related to ageing, such as cancer, a flu, or getting run-down.
“Signs of early HIV infection include flu-like symptoms such as headache, muscle aches, swollen glands, sore throat, fevers, chills, and sweating, and can also include a rash or mouth ulcers. Symptoms of later-stage HIV or AIDS include swollen glands, lack of energy, loss of appetite, weight loss, chronic or recurrent diarrhea, repeated yeast infections, short-term memory loss, and blotchy lesions on the skin, inside the mouth, eyelids, nose, or genital area.”
https://www.nia.nih.gov/health/hiv-aids/hiv-aids-and-older-adults
Furthermore, many participants in the BMC study believed that sexually transmitted infections could never be the cause of their symptoms, as their last risky sexual contact been ‘too long in the past’ to still have effects (BMC Public Health, 2018). Even more concerningly, once the older people in the study presented their symptoms to Health Care Professionals, these clinicians were more likely to pursue other lines of inquiry first, before considering that HIV may be the cause and completing a simple HIV test (BMC Public Health, 2018). This shows that HIV is not seen as a primary cause of concern for older people, both amongst themselves and among healthcare professionals.
Reason 3: Healthcare Bias
Many Health Care Professionals hold the belief that older people are ‘asexual’, or are not engaging in risky sexual behaviour (Clinical Medicine Journal, 2017). Thus, HCPs are less likely to ask their older patients about topics relating to sex, STI transmission and contraception. The older women in the study stated that as they aged, their HCPs started to ask them less about their sexual and reproductive health, and they felt a great loss of trust with the relevant professionals when this occurred (BMC Public Health, 2018). Furthermore, many patients did not want to ask HCPs for STI tests or HIV tests, due to fear of being laughed at or judged for having sexual contact.
This highlights the need for Health Care Professionals to be more proactive in asking their older clients about their sexual/reproductive health, and to integrate questions about sexual health into their general health check appointments with older populations.
Reason 4: Lack of Knowledge on HIV
Many of the older straight and bisexual people questioned in the BMC study stated that they had very little knowledge of what HIV was, how it could be transmitted, and how to get tested, before getting their diagnosis. They highlighted that there are virtually no campaigns around HIV targeted at the over 50’s demographic specifically (BMC Public Health, 2018). Many HIV campaigns still tend to centre on gay men and are advertised in solely in LGBTQ+ spaces, especially areas where youth gather such as nightclubs, bars and online spaces (BMC Public Health, 2018). The older gay men in the study stated that they had more information, but as they got older, they felt ‘invincible’ compared to their peers, as they had reached their 50’s without contracting the virus.
Thus, like Reason 1, many older people feel like they do not need to get tested as this is not something that is highlighted to them or seen as relevant to them. Furthemore, many older people highlighted that even if they managed to garner up the confidence to get a test, they had no information about where to go, or how to access testing.
Reason 5: Testing Venue Unsuitability
The older people in the BMC study stated that they felt shame and stigma attached to attending their local sexual health clinic. They stated they felt afraid that someone would see them attending, and thus would draw attention to themselves – both from inside the clinic (‘why is that older person here?’) and from the external world (fear of bumping into someone on the street that they knew) (BMC Public Health, 2018). Many respondants stated that they would prefer that the GP completed HIV tests at the practice, rather than having to go to a sexual health clinic to get tested, but this was not a service offered to them. Furthemore, older people are less likely to be confident in using at-home testing kits, as the process often requires an internet connection and internet literacy, which is lower overall in older populations. In the BMC study, the older people stated that they would be afraid of ‘doing it wrong’ if they completed an at-home testing kit themselves, highlighting yet another barrier(BMC Public Health, 2018).
This point demonstrates the need for more easily accessible HIV testing, such as from the GP itself, or and integration of HIV testing into general health checks for older people.
The importance of HIV testing in people over 50
So, we've highlighted the risks associated with HIV infection in those aged over 50 years old. There are many reasons why people in this age bracket have been lower in accessing HIV testing, and ways in which HIV affects those over 50 in different ways to younger populations.
The take-home point is the importance of making HIV testing accessible to all, including not only the physical location of testing sites, but also the ways in which HIV testing is promoted and advertised among different groups. Stigma and a lack of knowledge of how to access HIV testing suggest current sexual health services may need to adapt to better meet the needs of over 50s. These may include offering HIV testing at GPs, or including them in other screenings, such as blood pressure monitoring or mammograms (BMC Public Health, 2018). Unless older people are made aware that they should be getting tested, and that they can be affected by HIV, the rates of positive HIV cases will continue to rise in this bracket until they are more effectively reached by HIV testing clinics and outreach campaigns.
National HIV testing week is successful at promoting HIV testing [43]. However, it is targeted at younger groups and MSM and as a result, older people in this study felt it was not relevant to them. This campaign may be a good opportunity to target the older group by tailoring promotion materials, for example to contain pictures of older people, or displaying materials at venues more appropriate to this group.(BMC Public Health, 2018)
If you would like to access HIV testing after reading this blog, please click here or here to find out the nearest HIV testing centre in your area. Furthermore, if you are struggling your sexual health or having relationship problems, SASH can offer you support and advice. You can get in touch with us by contacting us, or make a referral to our service on our website www.sashlondon.org
Relevant links:
BMC Public Health, 2018 https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-018-6118-x
Clinical Medicine Journal, 2017 https://www.rcpjournals.org/content/clinmedicine/17/6/508
https://journals.sagepub.com/doi/10.1177/1355819620943242
NIA, 2024 https://www.nia.nih.gov/health/hiv-aids/hiv-aids-and-older-adults
Journal of Health Services Research and Policy, 2020 https://www.tht.org.uk/hiv-and-sexual-health/living-hiv-long-term/ageing
AIDSMap, 2021 https://www.aidsmap.com/about-hiv/menopause-and-hiv
NHS, 2024 https://www.nhs.uk/conditions/hiv-and-aids/living-with/