Safer sex in older age: putting combination HIV prevention strategies into practice
Authors: Milton R F Crenitte, Fernanda Rick, Vivian I Avelino-Silva
Journal: The Lancet Healthy Longevity (2021)

Older adults are often left behind in prevention strategies aimed at preventing sexually transmitted infections (STIs), and often face barriers to HIV and STI prevention. Combination HIV prevention (CHP) promotes autonomy for older adults; however, this strategy is unknown to most geriatricians, gerontologists, and older adults in general. CHP is the coordinated, non-hierarchical use of different biomedical, structural, and behavioural interventions tailored to the needs and preferences of specific people and communities to prevent HIV and other STIs.1Kurth AE Celum C Baeten JM Vermund SH Wasserheit JN Combination HIV prevention: significance, challenges, and opportunities.Curr HIV/AIDS Rep. 2011; 8: 62-72Crossref PubMed Scopus (195) Google Scholar Biomedical interventions in CHP include HIV and STI testing and treatment; use of pre-exposure prophylaxis, post-exposure prophylaxis, condoms, and lubricants; vaccination for hepatitis A virus, hepatitis B virus, and human papillomavirus; and male circumcision.1Kurth AE Celum C Baeten JM Vermund SH Wasserheit JN Combination HIV prevention: significance, challenges, and opportunities.Curr HIV/AIDS Rep. 2011; 8: 62-72Crossref PubMed Scopus (195) Google Scholar Behavioural interventions help to enrich patients' knowledge and risk perception of HIV and STIs through education and incentives that reduce exposure, including education counselling strategies. Structural interventions target political and cultural conditions to reduce the susceptibility of individuals or groups to HIV and other STIs. Examples of structural interventions include political and legal actions against racism, sexism, and homophobia; promotion of human rights; and education and awareness campaigns. CHP should involve government representatives, private sectors, and community members who cooperatively contribute to delivering a package of interventions that match the epidemiological profile of the target population. Despite its advantages, CHP is insufficiently disseminated in the geriatric population despite their increasing need for tailored prevention strategies.2Roberson DW Meeting the HIV prevention needs of older adults.J Assoc Nurses AIDS Care. 2018; 29: 126-129Crossref PubMed Scopus (10) Google Scholar People living with HIV who are receiving antiretroviral therapy (ART) have a life expectancy and quality of life that is similar to that of age-matched individuals without HIV.3Gakhar H, Kamali A, Holodniy M. Health-related quality of life assessment after antiretroviral therapy: a review of the literature. Drugs; 73: 651–72.Google Scholar Simultaneously, older adults have increased opportunities for new sexual partnerships given the past decades' cultural and medical advances (eg, acceptance of marriage terminations, promotion of sexual liberty, and improvements in sexual performance with hormonal and erectile dysfunction treatments).4Taylor A Gosney MA Sexuality in older age: essential considerations for healthcare professionals.Age Ageing. 2011; 40: 538-543Crossref PubMed Scopus (122) Google Scholar Hence, it is not uncommon for people older than 50 years to be newly diagnosed with HIV.5Sankar A Nevedal A Neufeld S Berry R Luborsky M What do we know about older adults and HIV? A review of social and behavioral literature.AIDS Care. 2011; 23: 1187-1207Crossref PubMed Scopus (106) Google Scholar Estimates in the USA suggest that more than 50% of all people living with HIV are 50 years or older, and a French study has shown that people living with HIV and receiving ART in this age group has increased 7–19% between 1993 and 2012.6Costagliola D Demographics of HIV and aging.Curr Opin HIV AIDS. 2014; 9: 294-301Crossref PubMed Scopus (66) Google Scholar In Brazil, HIV diagnoses increased 9·3–12·7% between 2009 and 2019 in people 50 years or older.7Ministério da Saúde do BrasilBoletim Epidemiológico de HIV e AIDS número especial.http://www.aids.gov.br/pt-br/pub/2020/boletim-epidemiologico-hivaids-2020Date: December, 2020Date accessed: June 16, 2021Google Scholar However, older adults are less likely to have HIV and STI testing and more likely to have late HIV diagnosis than younger people.2Roberson DW Meeting the HIV prevention needs of older adults.J Assoc Nurses AIDS Care. 2018; 29: 126-129Crossref PubMed Scopus (10) Google Scholar Older adults are often considered asexual by family members and providers.2Roberson DW Meeting the HIV prevention needs of older adults.J Assoc Nurses AIDS Care. 2018; 29: 126-129Crossref PubMed Scopus (10) Google Scholar Because of this perception, access to HIV and STI prevention (eg, biomedical strategies other than condoms) is often reduced for older adults. ART-based interventions can be contraindicated in older adults due to comorbidities or its potential side-effects. Older adults who engage in sexual activities rarely acknowledge their susceptibility to HIV and other STIs, leading to insufficient uptake of prevention methods.2Roberson DW Meeting the HIV prevention needs of older adults.J Assoc Nurses AIDS Care. 2018; 29: 126-129Crossref PubMed Scopus (10) Google Scholar, 8Stall R AIDS risk behaviors among late middle-aged and elderly Americans.Arch Intern Med. 1994; 154: 57Crossref PubMed Google Scholar A study done in Brazil showed that 39% of older adults living with HIV did not use condoms consistently. The reasons for not using condoms consistently included preferring sex without condoms, beliefs that condoms ruin the moment, not having immediate access to a condom, not knowing how to use a condom, being concerned about erectile dysfunction, anticipating that monogamous relationships are free from HIV risk, and the accusation of infidelity from partners that are associated with condoms.9Serra A de Lima Sardinha AH Pereira ANS Lima SCVS Percepção de vida dos idosos portadores do HIV/AIDS atendidos em centro de referência estadual.Saúde em Debate. 2013; 7: 294-304Crossref Google Scholar Older heterosexual couples might use condoms less often once unplanned pregnancies no longer occur. Additionally, reduced vaginal lubrification can prevent condom use in this population.5Sankar A Nevedal A Neufeld S Berry R Luborsky M What do we know about older adults and HIV? A review of social and behavioral literature.AIDS Care. 2011; 23: 1187-1207Crossref PubMed Scopus (106) Google Scholar, 8Stall R AIDS risk behaviors among late middle-aged and elderly Americans.Arch Intern Med. 1994; 154: 57Crossref PubMed Google Scholar, 9Serra A de Lima Sardinha AH Pereira ANS Lima SCVS Percepção de vida dos idosos portadores do HIV/AIDS atendidos em centro de referência estadual.Saúde em Debate. 2013; 7: 294-304Crossref Google Scholar Challenges concerning sex in older populations should also be considered. When an older adult lives with family members, the absence of privacy might motivate quicker sexual intercourse, with no time or opportunity to engage in prevention methods.2Roberson DW Meeting the HIV prevention needs of older adults.J Assoc Nurses AIDS Care. 2018; 29: 126-129Crossref PubMed Scopus (10) Google Scholar, 8Stall R AIDS risk behaviors among late middle-aged and elderly Americans.Arch Intern Med. 1994; 154: 57Crossref PubMed Google Scholar, 9Serra A de Lima Sardinha AH Pereira ANS Lima SCVS Percepção de vida dos idosos portadores do HIV/AIDS atendidos em centro de referência estadual.Saúde em Debate. 2013; 7: 294-304Crossref Google Scholar Other limitations can ensue for older adults living in nursing homes,4Taylor A Gosney MA Sexuality in older age: essential considerations for healthcare professionals.Age Ageing. 2011; 40: 538-543Crossref PubMed Scopus (122) Google Scholar where sexual activities are not expected and are sometimes not allowed. There is also an absence of sex education and prevention campaigns that target older adults, and studies suggest that older adults and health-care providers can be reluctant to talk about sex during appointments.4Taylor A Gosney MA Sexuality in older age: essential considerations for healthcare professionals.Age Ageing. 2011; 40: 538-543Crossref PubMed Scopus (122) Google Scholar This scarcity of opportunity for open communication hinders HIV and STI prevention among older adults.2Roberson DW Meeting the HIV prevention needs of older adults.J Assoc Nurses AIDS Care. 2018; 29: 126-129Crossref PubMed Scopus (10) Google Scholar, 4Taylor A Gosney MA Sexuality in older age: essential considerations for healthcare professionals.Age Ageing. 2011; 40: 538-543Crossref PubMed Scopus (122) Google Scholar, 8Stall R AIDS risk behaviors among late middle-aged and elderly Americans.Arch Intern Med. 1994; 154: 57Crossref PubMed Google Scholar CHP can be adapted to address the specific needs of older adults. Challenges and potential solutions for CHP in the geriatric population are shown in the appendix. No individual strategy is sufficient by itself and multiple biomedical intervention strategies work in combination and can be adopted simultaneously (figure). Interventions are dynamic and preferences can vary from person to person and change over time, highlighting that CHP is a patient-centred approach that is tailored to individual needs and lifestyles.1Kurth AE Celum C Baeten JM Vermund SH Wasserheit JN Combination HIV prevention: significance, challenges, and opportunities.Curr HIV/AIDS Rep. 2011; 8: 62-72Crossref PubMed Scopus (195) Google Scholar This approach is also consistent with the principle of autonomy, one of WHO's pillars of active ageing.10WHOActive ageing: a policy framework. World Health Organization, Geneva2002Google Scholar Although the end of the HIV epidemic remains distant, both acknowledging older adults' sexuality in combination with CHP can do much to reduce the spread of HIV in this population. We declare no competing interests. We thank João Paulo Tiago (Sao Paulo, Brazil) for designing the figure. Download .pdf (.12 MB) Help with pdf files Supplementary appendix