HIV and other sexually transmitted infections in older adults
Authors: Ibraheem M Karaye, Corinne M Kyriacou
Journal: The Lancet Healthy Longevity (2024)

Every country is experiencing growth in the number and the proportion of older people in the population. By 2030, 17% of the global population will be aged 60 years or older, and between now and 2050, the world's population of older adults will double to 2·1 billion.1WHOWHO's work on the UN Decade of Healthy Ageing (2021–2030).https://www.who.int/initiatives/decade-of-healthy-ageingDate accessed: December 7, 2023Google Scholar While sexual activity has long been a misunderstood aspect of ageing, increased longevity, changing societal norms, and the availability of pharmacotherapies have led to sexual activity being more frequently sustained into older adulthood.2Steckenrider J Sexual activity of older adults: let's talk about it.Lancet Healthy Longev. 2023; 4: e96-e97Summary Full Text Full Text PDF Google Scholar Continued sexual activity elevates the likelihood of contracting sexually transmitted infections (STIs), including HIV.3Minichiello V Hawkes G Pitts M HIV, sexually transmitted infections, and sexuality in later life.Curr Infect Dis Rep. 2011; 13: 182-187Crossref PubMed Scopus (0) Google Scholar Advancements in antiretroviral therapy (ART) and global treatment programmes have substantially improved the life expectancy of people with HIV, aligning it with that of HIV-negative people.4De Francesco D Wit FW Bürkle A et al.Do people living with HIV experience greater age advancement than their HIV-negative counterparts?.AIDS. 2019; 33: 259-268Crossref PubMed Scopus (83) Google Scholar However, there is a notable scarcity of empirical studies comprehensively assessing the global and regional burden and trends of HIV and other STIs among older adults. In The Lancet Health Longevity, Liewen Fu and colleagues5Fu L Tian T Wang B et al.Global, regional, and national burden of HIV and other sexually transmitted infections in older adults aged 60–89 years from 1990 to 2019: results from the Global Burden of Disease Study 2019.Lancet Healthy Longev. 2024; 5: e17-e30Summary Full Text Full Text PDF Google Scholar report an evaluation of the global, regional, and national burdens and trends of HIV and other STIs among older adults aged 60–89 years in 204 countries from 1990 to 2019, using incidence data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019. The authors found that, globally, the age-standardised incidence rate of HIV declined by around 2% per year during the study period, while the age-standardised incidence rate of other STIs (comprising syphilis, chlamydia, trichomoniasis, gonorrhoea, and genital herpes) remained stable. However, upon disaggregating the data by sex, age, and region, varying trends emerged. For instance, the age-standardised incidence rates of HIV increased in many regions, including eastern Europe, central Asia, and high-income Asia Pacific, while the incidence rates of STIs increased only in high-income North America and Australasia. The authors also assessed disability-adjusted life-year (DALY) rates, which showed no substantial changes for HIV and decreases for STIs overall worldwide, with differential trends across disaggregated regional and demographic subgroups. Additionally, the authors identified an inverse association between the Socio-demographic Index (SDI) and the age-standardised incidence and DALY rates of HIV, with countries of higher SDI having lower rates of HIV. Fu and colleagues' results are important for several reasons. First, they underscore the importance of disaggregating data, as this process often reveals noteworthy changes in burden and trends, exposing groups at increased risk requiring focused interventions.6PAHOWHOIS4H toolkit—knowledge capsules: data disaggregation in public health.https://www3.paho.org/ish/images/toolkit/IS4H-KCDD-EN.pdfDate accessed: December 7, 2023Google Scholar Second, the findings offer baseline estimates for age-standardised incidence rates and DALYs globally, as well as across regions and demographic subgroups. With older adults constituting an increasing proportion of individuals living with HIV, these estimates can be used to track and benchmark progress towards the UNAIDS 95-95-95 targets set in 2020, which aim for 95% of all people with HIV to know their status, 95% of those with HIV to receive sustained ART, and 95% of those receiving ART to attain viral suppression by 2025. The finding of negative associations of SDI with the age-standardised incidence rates and DALYs of HIV and other STIs, along with the identification of regions with higher-than-expected age-standardised incidence rates and DALY rates (sub-Saharan Africa, Oceania, tropical Latin America, central Latin America, and the Caribbean) highlights the need for concerted efforts and sustained interventions in low-income and middle-income countries. Initiatives, including HIV and STI testing campaigns, education, literacy and awareness programmes, and outreach services tailored to older adults facing challenges in accessing health care, must be prioritised. Health-care systems need to be equipped to cater to older adults with HIV. Kiplagat and colleagues7Kiplagat J Tran DN Barber T et al.How health systems can adapt to a population ageing with HIV and comorbid disease.Lancet HIV. 2022; 9: e281-e292Summary Full Text Full Text PDF PubMed Scopus (17) Google Scholar have proposed incorporating a target for people with HIV to reach 90% of the average regional life expectancy across different age strata. Achieving this target necessitates a reduction in late diagnoses, alongside factors such as ensuring access to ART, supporting adherence, and providing holistic care for people with HIV. We recommend further research directions that could improve on Fu and colleagues' study. First, the trend analysis used by the authors produced an estimated annual percentage change (EAPC) over the entire study period, 1990–2019. Although undoubtedly useful and aligned with the analytic framework of GBD, further studies could use joinpoint regression or equivalent methods to identify inflection points—significant changes in trend—assessing the annual percentage changes over shorter time periods. Trends might not always be uniform or linear over the entire study period, as assumed in Fu and colleagues' study. Second, previous studies have reported that older adults are less likely to be diagnosed early with HIV or STIs, as they are often not regarded as being at high risk.8Justice AC Goetz MB Stewart CN et al.Delayed presentation of HIV among older individuals: a growing problem.Lancet HIV. 2022; 9: e269-e280Summary Full Text Full Text PDF PubMed Scopus (17) Google Scholar They are also more likely to face stigma for their age and HIV status, negatively affecting their diagnosis and treatment.9The Lancet Healthy LongevityAgeing with HIV.Lancet Healthy Longev. 2022; 3: e119Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar Moreover, older adults with HIV are more likely to have multimorbidity and accelerated ageing, negatively impacting their health-related quality of life and increasing their risk of death.9The Lancet Healthy LongevityAgeing with HIV.Lancet Healthy Longev. 2022; 3: e119Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar To assist in identifying mortality benchmarks and setting evidence-based goals to reduce HIV mortality in this population, further studies could consider assessing the global, regional, and national burden and trends of HIV mortality among older adults. Finally, Fu and colleagues highlighted a concerning upward trend in the age-standardised incidence rate of STIs in North America. This finding is consistent with existing literature. Notably, in the USA, the incidence of STIs among people aged 65 years and older more than doubled between 2000 and 2022.10Centers for Disease Control and PreventionNCHHSTP AtlasPlus.https://www.cdc.gov/nchhstp/atlas/index.htmDate accessed: December 7, 2023Google Scholar While potential factors—including a lack of awareness, low use of protection, changing relationship dynamics, altered immune function, stigma and shame, health-care provider assumptions, improved health, and longer lifespans of older individuals—could contribute to this surge in incidence, empirical studies are needed to identify the individual and contextual drivers behind these trends. Understanding why the increase is most prominent in North America, particularly for chlamydia, trichomoniasis, and genital herpes, in comparison to other regions, is important for developing targeted interventions and educational campaigns to address the unique challenges faced by older adults in preventing and managing STIs in the region. The UN Decade of Healthy Ageing (2021–30) aims to improve health equity and, thereby, the lives of older adults.1WHOWHO's work on the UN Decade of Healthy Ageing (2021–2030).https://www.who.int/initiatives/decade-of-healthy-ageingDate accessed: December 7, 2023Google Scholar To succeed, the sexual health of ageing populations must be further investigated and prioritised. We declare no competing interests. Global, regional, and national burden of HIV and other sexually transmitted infections in older adults aged 60–89 years from 1990 to 2019: results from the Global Burden of Disease Study 2019Although the incidence and DALY rates of HIV and STIs either declined or remained stable from 1990 to 2019, there were regional and demographic disparities. Health-care providers should be aware of the effects of ageing societies and other societal factors on the risk of HIV and other STIs in older adults, and develop age-appropriate interventions. The disparities in the allocation of health-care resources for older adults among regions of different SDIs should be addressed. Full-Text PDF Open Access