Tuesday, December 19, 2006

HIV Over 50: Stigma leading to insufficiency of prevention-Jessica B. Castronovo

Over the past 25 years, HIV/AIDS has been affecting many aspects of society at astonishing rates. Public health practitioners (doctors, policy makers, educators, etc) in all spheres of influence have been working hard to put together comprehensive and effectual prevention efforts targeting those at risk for HIV/AIDS infection. Unfortunately these care providers have focused on small groups that are considered at risk due to their lifestyle (IV drug users, men who have sex with men etc). Many of these efforts have been considered successful. In their haste to address this very important issue of HIV/AIDS prevention, stigma has prevented practitioners from even identifying people over the age of fifty as a group at risk.

Older adults are living in a society where they are stigmatized because of their age. It is thought by much of society, and often themselves, that older adults are not vital, pleasure seeking individuals. As a result, older adults are not viewed as at risk for a HIV/AIDS, which is often considered a disease of the young and/or risk courting. The stigma of being older, combined with the stigma of the behaviors which put one at risk for HIV/AIDS infection are placing older adults at great and unnecessary risk of infection. Further more, Public Health has failed older adults in the realm of HIV/AIDS prevention. In many of the spheres that impact an individual’s life, where the various types of Public Health practitioners can intervene, there is scarce education, acceptance and care. In this paper I will outline and explore the failures of Public Health utilizing the Social Ecological Model, which draws the spheres of influence in a person’s life, going from the broad world of state and federal policy down to the individual interactions a person has. All spheres are places in which Public Health can intervene with prevention efforts-and often it is done, with other populations-but older adults are failed in multiple spheres.

The US Centers for Disease Control and Prevention (CDC, 2003a) estimate that the number of adults over the age of 55 living with HIV/AIDS in the United States increased by at least 107% from 1998-2002. This is a larger increase then any other adult age group. Between 10% and as high as 18% of people living with HIV/AIDS are over the age of fifty and 25% of these cases are in persons over the age of 60 (Feldman, 1994). It can also be assumed that there is actually a higher rate of HIV/AIDS in the older adult population then the statistics reflect, but they have not been tested. Elderly have been found to be less likely to be tested the any other group (Doup, 1994; Feldman, 1994; Jones, 1999). In contrast, the rate of infection of children age 5 and younger is less then 1% of the AIDS cases (CDC, 1998). The level of perception of risk does not coincide with these statistics on infection, the CDC Behavioral Risk Factor Surveillance System, 2000 Survey reveal that among adult respondents age 55-64, 81% reported no risk for HIV and 15.1% reported a low chance of getting HIV (CDC, 2003a).

From the data, it is clear that HIV/AIDS infection is a real issue among older adults and in turn the responsibility of Public Health practitioners.

Societal Sphere of Failure
Social Structure, Policy and Systems are the broadest and largest level of influence when discussing the prevention of a disease from a public health standpoint. These influences may have been local, state or federal policies regulating prevention and care efforts. Overall very little has been done at the societal level to dispel society’s ageist views about older adults and their risk of HIV/AIDS.

When one thinks of HIV prevention campaigns, the most popular methods address the need to use condoms or clean needles. What is also apparent in these campaigns is a younger population is being targeted. There is usually flashy writing and young innocent or confused, attractive looking people making safer sex look enticing. Older adults have been left out of most HIV/AIDS prevention campaigns, including the brochure driven ones. Only 14 states in the United States have print information about HIV/AIDS geared specifically towards older adults (Apreal, et al, 2004). Nancy Oreal, et al also call into question the quality of the printed prevention efforts reaching the intended audience. The availability does not appear widespread or in multiple languages. The exclusive use of print material also leaves out the group of older adults who are illiterate. With the factor of illiteracy comes increased chance of poverty, substance abuse and depression-all increased risk factors for HIV/AIDS.

The lack of literature available has been found to be insufficent in fundamental ways. The focus of the literature geared toward older adults was primarily education. It usually included a list of facts pertaining to older adults higher risk factors for HIV/AIDS. States did include in their literature aimed at older adults myths and stereotypes around HIV/AIDS, basic facts about HIV/AIDS and basic STD prevention strategies (i.e. condom use). There was no mention of physiological aging factors, which have been linked to decreased immune systems; vaginal wall thinning and less vaginal lubrication may increase the risk of HIV in sexually active older women (Zablotsky, 1998). The mere fact that the ads and pamphlets do not generally include older adults perpetuates the normative myths surrounding older adults and their risk for HIV. Our society continues to believe that older adults do not engage in behaviors that put them at risk, which is not true. “An increasingly high percentage of newly identified AIDS cases in older adults are due to HIV transmission through risky sexual behaviors (Maes & Louis, 2003, ” especially male-to-male sexual contact (Strombeck &Levy, 1998). “Despite the dominant stereotypes of an ‘asexual older person’, studies on sexual activity among older adults showed that a high percentage (81.5%) of subjects over age 50 were involved in one or more sexual relationships (Inelmen, et al, 2005).”

Studies have been done to document the lack of impact Public Health prevention campaigns have had on the older adult community. The majority of people over the age of 50 with AIDS reported that they had not received very much information on prevention. When they did report receiving information about HIV/AIDS, it was through the mass media. In a focus group in New York City, older adults over the age of 50 relayed that they did not perceive HIV/AIDS prevention messages as targeted towards them. (Klein, et al, 2001). According to researchers Schable et al,1996 “…older women with heterosexually acquired HIV are less likely to have used a condom before their HIV diagnosis and less likely to have been tested for HIV.” when compared with older groups of women. This is a living example of the need for a condom use message not reaching an at risk population, whether it be not identifying with the issues of risk or not even getting the message of the importance of condom use. Older adults were raised to use condoms as birth control, making post-menopause pregnancy no longer a concern, and an issue that getting addressed. They are instead applying this condom use message to their children and grandchildren, not themselves.

Institutional Sphere of Failure
The medical community is a strong partner when it comes to addressing prevention and treatment of diseases. It is often relied upon to be a place of formal and informal rules and regulations. These are thought of as safety nets to teach people about disease and its prevention or treatment. The main line of defense in the medical community is thought to be the Primary Care Physician (PCP). In the area of HIV/AIDS education, prevention and treatment the PCP has fallen dangerously short.

At the heart of this failure is the issue that PCP’s buy into the ageist myths of older age equaling celibacy and sobriety (Engle, 1998). It remains easy for the PCP to ignore HIV/AIDS as an issue because elements of aging mimic symptoms of HIV/AIDS. Common symptoms of HIV/AIDS that can be attributed to aging are memory loss, loss of muscle tone and fatigue. Some studies show that “…over 90% of those 50 years and older have never had an HIV test (Maes & Louis, 2003).”

The result of ageist views of many PCP’s is a “don’t ask, don’t tell” standard of care around the subject of behaviors that would put an older adult at risk for HIV/AIDS. This can lead to serious consequences. As stated previously in this paper, the number of adults over the age of 55 living with HIV/AIDS increased by 107% from 1998-2002. This is the largest increase of all adult age groups (CDC, 2003a).

It is not to say that PCP’s do not discuss sexuality with their patients. There has been a large increase in the use of and acceptance of sexual enhancement drugs. The introduction of this class of drugs has increased the sexual potency of men and frequency of sexual intercourse. This increase in prescribing appears to have correlated with “an increasingly high percentage of newly identified AIDS cases in older adults “…due to HIV transmission through risky sexual behaviors (Maes & Louis, 2003)”. When paired with the hands off approach PCP’s have had of truly addressing older adult sexuality it can be dangerous. Additionally there does not appear to be a protocol that is followed for pairing education about HIV/AIDS with the prescribing of sexual potency medications.

In regards to the societal sphere’s potential interaction with the PCP’s, there is no current standard public health outreach to the medical community that serves to enhance awareness of older adults as an at risk population for HIV/AIDS. As an example, among PCP’s, there is no push to have the doctors ask a series of risk factor questions during the patient’s medical visit. In contrast, adolescents and young adults are asked standard questions about their sexual behavior and drug use-risk factors that are significant in both young and old.

Individual Sphere Failure
The most pointed and specific level of influence is the individual. This is where prevention efforts incorporate health behavior theory in order for people to change their behaviors. There have been very few interventions that have been implemented to target the older adult and their risk of HIV/AIDS. Among efforts that have been made to target older adults all are lacking in key elements that have made prevention efforts with other groups viable. Studies have shown that HIV/AIDS prevention efforts that teach sexual negotiation skills and increase availability of condoms improve self-efficacy, which is a key element to changing behavior. If an individual believes in a behavior or intervention and feel they can do it then they are more likely to follow through with that healthier behavior.

The theory of reasoned action is a particularly useful and informative way to identify effective intervention programs. In a study done by Jemmott & Jemmott (1991) surveying young black women, those who registered more favorable attitudes toward condoms and those who perceived subjective norms more supportive of condom use reported firmer intentions to use condoms in the next three months. Key behavioral beliefs are related to attitudes centered on the adverse effects of condom use on sexual enjoyment. Key normative influences were respondents' sexual partners and mothers. However, women's own attitudes were a stronger determinant of intentions to use condoms than were their perceptions of normative influences, particularly among women with above average AIDS knowledge. These results suggest that the theory of reasoned action provides a potentially useful conceptual framework for interventions to change a key AIDS risk behavior among women. In turn it can be expanded to other groups who have been stigmatized and disempowered (such as older adults).

In terms of research to establish effective prevention methods, very little HIV research has explored the channels and methods of communication that are more frequently used by, acceptable to, or effective with older people. The biological, psychological and social issues of people over the age of 50 need to be taken into account when developing a prevention program.

Current prevention strategies for older adults are more centered around providing information (safer sex, the etiology of HIV and modes of transmission). An example of this method is the Senior HIV Intervention Project (SHIP) originally located in the Dade, Broward and Palm Beach Counties of Florida. SHIP started in 1997 by the Department of Public Health in response to the dramatic increase in HIV/AIDS among the elders of Dade, Boward and Palm Beach Counties. It was recently discontinued in Palm Beach County due to the person running the program becoming too elderly to do so. There is one Educational Coordinator overseeing the program in Broward and Dade Counties. It is integrated with general HIV/AIDS prevention for all populations. This is a program which trains older adult peer educators to present educational and safer sex seminars at retirement communities, focusing on the etiology of HIV and modes of transmission and the importance of knowing one’s HIV status by testing. Trained AIDS educators meet with health care professionals and aging service workers to help them understand the risks posed to older adults by HIV. This is done in small group meetings (Agate, et al, 2003). While a step in the right direction, this program, along with others that are similar in Chicago, IL and Baltimore, MD, is missing a key element that would cause change on the individual level. While basic education is important, it can be shown repeatedly in public health that simply knowing about something does not guarantee that an individual will translate it into their daily lives. There is no emphasis on the concrete issues that put individuals at risk such as condom availability and sexual negotiation skills. Attacking HIV/AIDS prevention with emphasis on self-efficacy with development of personal attitudes towards condoms, discussing their partner’s status and making decisions based upon the information provided. Simply teaching how to put a condom on and how to ask a partner what their sexual history paired well with the education that SHIP and other programs like it would be the start to a better prevention model.

In discussions with the Educational Coordinator, she did acknowledge this deficit and has been trying to remedy this by offering the prevention education focusing on sexual negotiation and condom use to all ages. Unfortunately she has found that older adults have not been actively participating in these educational sessions. She did acknowledge that this is an issue, but has little funding to expand her programming to be more age and culturally sensitive.

It does not appear that much research has been done on whether the intervention of SHIP has made a real difference in people’s lives. What has been measured after exposure to SHIP and other programs like it are the participant’s level of knowledge about HIV/AIDS. There is no discussion about attitudes towards prevention techniques such as using the condom they are told will prevent HIV and negotiating the use of this condom. There was also no data available on rates of infection after exposure to the program. Incidences of HIV/AIDS have also increased in Dade, Broward and Palm Beach County since the introduction of this prevention program.

In conclusion, HIV/AIDS prevention has failed older adults in many spheres of influence in their lives. On a Systems level prevention efforts are obviously directed towards the young, IV drug users and men who have sex with men. On the organizational level, it is the medical community, captained by PCP’s where HIV/AIDS is rarely discussed with older adults and sexual potency medications are prescribed with little safer sex discussion. In the individual sphere, HIV/AIDS prevention methods are missing as a largely important part of prevention efforts-giving individuals life skills to deal with situations where they could be put at greater risk for HIV exposure. It is well documented in research done on prevention programs and programs aimed at changing people’s behavior that the most important determinant of the impact of a prevention effort is change in important attitudes translated into people’s true actions. There does not appear to be sufficient data to determine if the small prevention efforts have made a true impact, but with their emphasis on education and exclusion of theoretically supported necessary elements such as sexual negotiation and condom availability, they are failing older adults. Public Health must take responsibility for the increase in the HIV infection rate of older adults that is known (i.e. those who have been tested) and for the fact that the data in general on this issue is paltry and then change accordingly.

Agate, L.L, Mullins, J.M., Prudent, E.S & Liberti, T.M. (2003) Strategies for Researching Retirement Communities and Aging Social Networks: HIV/AIDS Prevention Activities Among Seniors in South Florida. JAIDS: Journal of Acquired Immune Deficiency Syndromes, 33 (2): S238-S242.

Centers for Disease Control and Prevention (1998). CDC: Basic Statistic-Cumulative Cases-United States, 2000.

Centers for Disease Control and Prevention. (2003a). Cases of HIV Infection and AIDS in the United States, 2002: Table 10. Estimated numbers of persons living with AIDS by year, and selected characteristics, 1998-2002-United Sates. HIV/AIDS surveillance report edition, 14 (2). Atlanta, GA: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services.

Coon, David W. , et al. (2003) Designing Effective HIV/AIDS Social and Behavioral Interventions for the Population of Those Age 50 and Older: Interventions and Research Methods for Use with Older Populations. JAIDS: Journal of Acquired Immune Deficiency Syndrome: 33(2): S194-S205.

Doup, Liz. The Aging of AIDS. Miami Herald: August 28, 1994; Section J; page 1; Column 1.

Engle, Laura. Old AIDS: Body Positive; 11:1. (www.bodypositive.com/bp/jan98/old_aids.html)

Feldman, Mitchell. (1994) Sex, AIDS and the Elderly. Archives of Internal Medicine:15:1, p19.

Gonzalez, Edith. Educational Coordinator of Boward and Dade County Senior HIV Intervention Program, Boward County Department of Public Health. Interview 12/7/2006.

Guiding Principles of the Florida HIV/AIDS and Aging Task Force. (amhserver.fmhi.usf.edu/shapre/HAATF-GuidingPrinciples2000.html)

www.hivoverfifty.org/tip.html (Obtained 11/12/2006).

Inelman, E. M. , et al. (2005) HIV/AIDS in older adults: A Case Report and Literature Review. Geriatrics, September: 26-30.

Jemmott, L.S. & Jemmott, J.B. 3rd . (1991). Applying the theory of reasoned action to AIDS risk behavior: condom use among black women. Nursing Research, 40(4):228-34.

Klein, S.J., et al (2001). Age-Appropriate HIV Prevention Messages for Older Adults: Finding from Focus Groups in New York State. Journal Public Health Management, 7(3): 11-18.

Maes, C.A. & Louis, M. (2003). Knowledge of AIDS, Perceived Risk of AIDS, and At-Risk Sexual Behaviors Among Older Adults. Journal of the American Academy of Nurse Practitioners, 15(11): 509-516.

Medicaid and HIV/AIDS Fact Sheet. Published by AIDS Action. (www.the body.com/aac/Medicaid.html).

Orel, N.A., Wright, J.M & Wagner, J. (2004). Scarcity of HIV/AIDS Risk-Reduction Materials Targeting the Needs of Older Adults Among State Departments of Public Health. The Gerontologist, 44 (5): 693-696.

Schable, B., Chu, S.Y. & Diaz, T. (1996) Characteristics of women 50 years or older with heterosexually acquired AIDS. American Journal of Public Health, 86 (11): 1616-1618.

Sormanti, M., Wu, E., El-Bassel, N. (2004) Considering HIV Risk and Intimate Partner Violence Among Older Women of Color: A Descriptive Analysis. Women and Health, 39 (1): 45-63.

Stall, R & Cantania, J (1994). AIDS Risk Behaviors Among Late Middle-aged and Elderly Americans. Archives of Internal Medicine, 154: 57-163.

Strombeck, R. (1998). Educational Strategies and Interventions Targeting Adults Age 50 and Older For HIV/AIDS Prevention. Research on Aging. 20(6): 23-28.


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