On HIV testing day, we ask why, as rates of new diagnosis of HIV decline across the world, late diagnoses continue to rise in older adults
HIV prevention strategies (including intensive testing of people at high risk of acquiring HIV and use of pre-exposure prophylaxis (PrEP)) have reduced the number of new diagnoses of HIV. However, rates of new diagnosis have continued to rise among older people (those aged 50 years and above).1 When compared to younger people, people aged 50 and above are also more likely to be diagnosed late (with a CD4 count of <350).2 This is of concern because late diagnosis is associated with increased risk of mortality, poorer health and transmission of HIV to sexual partners.
Why are new diagnoses still rising in people aged 50 and above?
Many people remain sexually active well beyond their fifties.3 When compared to younger people, people aged 50 and above report being less concerned about sexually transmitted infections, including HIV.4 There are several potential reasons for this: for example, people may find themselves newly single and/or seeking new relationships in middle or older age. People emerging from long-term relationships may have missed the safe sex education and campaigns received by younger people. They may be embarrassed about discussing their sexual health with healthcare professionals.5 In addition, healthcare providers are less likely to initiate discussions about sexual health with older people, often basing these decisions on stereotypes of older people as asexual or monogamous.5
What are the barriers to HIV testing in people aged 50 and above?
People aged 50 and above are less likely to seek an HIV test than younger people, and healthcare workers are less likely to offer older people an HIV test. Two linked studies shed light on barriers to HIV testing among people aged 50 and above.6,7 Youssef et al. conducted in-depth interviews with 20 people living with HIV who been diagnosed late and 20 clinicians who were involved in their care prior to their diagnosis.6,7 People living with HIV were aged between 52 and 80 years. They included men (70%) and women (30%), and those who described their sexual orientation as heterosexual (60%), gay (30%) and bisexual (10%).6 The clinicians worked in various specialities including medicine (50%), surgery (35%) and acute/emergency medicine (15%).7
The findings of these two studies showed substantial overlap between barriers to seeking an HIV test and barriers to offering an HIV test to older people. Most barriers to testing were potentially modifiable. To guide the development of interventions to facilitate HIV testing of older people, we have categorised these barriers according to the Capability, Opportunity, Motivation Behaviour (COM-B) framework. 8
Potentially modifiable barriers to seeking an HIV test identified in interviews with people aged 50 and above who were diagnosed late with HIV 6
Potentially modifiable barriers to offering an HIV test to people aged 50 and above identified in healthcare professionals 7
Recommendations for interventions to increase HIV testing in older adults
Increase capability by:
- Targeting older people in HIV/health promotion messages which include information about medical advances in HIV, and practical advice such as where to go for an HIV test
- Updating clinicians who do not work in sexual health on HIV testing guidance, consent procedures and common conditions seen in people living with HIV
Enhance motivation by:
- Identifying and addressing misconceptions about HIV and doubts about the need for HIV testing in older people
- Identifying and addressing clinicians’ concerns about initiating discussions about sex or HIV testing in older people
Increase opportunity by:
- Routinely offering HIV testing within current health screening practices regardless of age, other risk factors or the presence of symptoms
- Identifying and addressing misconceptions that are based on stigma and stereotyping
Tavoschi L, Gomes Dias J, Pharris A, Network EEHS. New HIV diagnoses among adults aged 50 years or older in 31 European countries, 2004-15: An analysis of surveillance data. Lancet HIV. 2017; 4(11):514-21
O’Halloran C, Sun S, Nash S, Brown A, Croxford S, Connor N et al. HIV in the United Kingdom: Towards zero 2030. 2019 report. In: England PH, editor. London2019.
de Visser R, Badcock P, Rissel C, Richters J, Smith A, Grulich A et al. Safer sex and condom use: Findings from the second Australian study of health and relationships. Sex Health. 2014; 11(5):495-504.
Syme M, Cohn T, Barnack-Tavlaris J. A comparison of actual and perceived sexual risk among older adults. J Sex Res. 2017; 54(2):149-60.
Taylor & Gosney, Sexuality in older age: essential considerations for healthcare professionals. Age and Ageing, 2011, 40 (5): 538-543
Youssef E, Wright J, Delpech V, Davies K, Brown A, Cooper V. Factors associated with testing for HIV in people aged ≥50 years: A qualitative study. BMC Public Health. 2018; 18(1):1204.
Youssef E, Wright J, Davies KA, Delpech V, Brown A, Cooper V. Factors associated with offering HIV testing to people aged ≥ 50 years: A qualitative study. Int J STD AIDS. 2022 03; 33(3):289-95.
Michie, S., van Stralen, M., West, R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement. Sci 2011, 23 (6): 42