Women Older Than 50
Studies have consistently demonstrated that many women are sexually active into their 60s. Even when we appreciate this, we tend to dismiss the possibility that any of our older patients may have HIV infection. We tend to assume that our patients are in stable relationships and presume there is no value to HIV testing.
It’s important to appreciate, however, that the number of people aged 50 and older who are living with HIV/AIDS has been increasing in recent years. It is estimated that almost one-fourth of all people with HIV/AIDS in the United States are age 50 and older. While this is partly due to the fact that HAART has extended the lives of many HIV-infected people, it is also attributed to newly diagnosed infections in people over 50.
The 2008 CDC analysis that showed that women comprised more than one-fourth of the individuals newly infected with HIV in 2006 also found that 25% of the new infections were in individuals (men and women) aged 40-49 (13,900 out of 56,300). Another 10% were in individuals aged 50 and over (5,800 of 56,300). Approximately 30% of the infections were a result of heterosexual contact.
Earlier data from the 1990s similarly showed over 10% of new AIDS cases occurring in people older than age 50.
Women of all ages can wrongly believe they are not at risk of contracting HIV. In one recent survey examining patient attitudes about HIV testing and knowledge about their own risk status, only 2% of approximately 850 women of various ages considered themselves at high risk for HIV infection despite the fact that almost half of them reported having had unprotected sex at some point with more than one partner. The women were patients of ob.gyn. members of ACOG’s Collaborative Ambulatory Research Network (Matern. Child Health J. 2009;13:355-63).
Older women are generally even less knowledgeable about HIV transmission and how to protect themselves than are younger women, and they are not concerned about undesired pregnancy. For these reasons, many older women may not be practicing safer sex, increasing their risk for HIV and other sexually-transmitted infections.
In a nine-question survey of 514 urban women aged 50 and older (mean age of 62), the majority of women scored poorly, answering four or fewer of the questions correctly. Eighty-four percent correctly identified unprotected heterosexual sex as a moderate- to high-risk activity, but only 13% identified condoms as being very effective in preventing HIV, and 18% said condoms are not at all effective (J. Amer. Geriatr. Soc. 2004;52:1549-53).
In another study aimed at assessing differences in the characteristics of individuals (both men and women) who refuse testing and those who accept it, investigators found that HIV test refusal was associated with female gender, white race, older age, and higher educational level (AIDS Patient Care STDS 2006;20:84-92).
Older women must be educated about their risk of heterosexual transmission and the fact that the risk for HIV acquisition has been increasing since 1994 in the United States. They need to understand that normal physiologic changes in the menopausal period such as thinning of the vaginal mucosa, increased susceptibility to vaginal abrasions during intercourse, and changes in their immune response can make them more vulnerable to disease acquisition or progression.
It also is important to educate them about the effectiveness of condoms and the importance of knowing the HIV status of their partners, because it is estimated that approximately 21% of infected individuals in the United States do not know their HIV status.
Most of all, our patients should understand that 30 years into the epidemic, we have demonstrated excellent survival in individuals on treatment, particularly among those who were diagnosed early and who are receiving HAART. A recent report from the CDC shows that average life expectancy after HIV diagnosis in the general population increased from 10.5 to 22.5 years from 1996 to 2005 (J. Acquir. Immune Defic. Syndr. 2010;53:124-130).
Interestingly, as the report points out, studies have shown that although HIV-infected women had a greater life expectancy to begin with, they showed a lesser magnitude of improvement than did men, particularly white men. (Women’s life expectancy changed from 12.6 to 23.6 years.) This observation highlights the importance of earlier diagnosis and link to care.
Knowing about the successes of HAART is important because women are less likely to opt out of HIV testing when they perceive the benefits. We can explain to patients – especially those who are apprehensive about the test – that the test is integrated into the annual health care panel (along with cholesterol and triglyceride testing, and genital cytology), and that, contrary to decades ago, we can treat and control HIV disease once it is diagnosed, which is more than we can do for certain types of cancer.