- Good sexual health is a correlate of positive health behaviors and outcomes. Engaging the older adult about their sexual behaviors can mediate better health outcomes.
- The health care team should screen older persons at each visit for high-risk behavior or evidence of sexually transmitted diseases, and then provide a tailored prevention message.
- Developing a routine way to elicit the patient’s sexual history that avoids judgmental attitudes and asks the patient for permission to discuss sexual function making it easier to gather the necessary information.
- In HIV discordant couples, there is a special need to emphasize safe sexual practices and full adherence to ART use.
- Use of erectile dysfunction medications and topical estrogen products for vaginal dryness can enhance sexual satisfaction. Prescriptions should be linked to specific educational efforts on safe sexual practices.
- PrEP is recommended as one prevention option in those at substantial risk of HIV acquisition for sexually-active older adult MSM, for older adult heterosexually active men and women, older adult injection drug users and HIV-discordant couples.
For those at high risk, sexual behavior has more often been defined through the narrow prism of HIV prevention. But, sexual health is broadly defined as more than just the absence of dysfunction or disease. Sexual health is a significant element contributing to the quality of life of every person including older adults living with HIV [1-3].
A recent study  noted that there are limited data on the associations between sexual health and physical, emotional, and cognitive function in older adults. How these associations differ by age and sex as well as health status remains unexplored. These associations and interactions must be even more nuanced when the variants of sexual behavior are also considered in the context of cultural norms and local attitudes. These factors can morph across the life-span, especially for the aging older adult with HIV.
In an aging society, medical management and supportive services related to changes in sexual health will increase. These changes are impacted by pharmaceuticals. Viagra sales range from 1.6 to 2 billion dollars annually . Lindau’s seminal USA data  showed that the prevalence of sexual activity for older adults decreased with age and that the activity numbers reported are driven by primarily by partner availability. Many people, particularly women, “lose” partners from divorce or death or severe illness like Alzheimer’s as they age . For women of color in the USA, especially older African American women, partner availability is markedly decreased in their community because of often endemic violence and high rates of incarceration [7, 8]. Notably, for older women the motivation to seek new relationships is driven not only by desire and pleasure seeking, but also the powerful need for companionship that can markedly reduce fears of loneliness and social isolation [9-11]. Social isolation is common in older adults and can be asscociated with depression that is poorly managed. For many older adults with HIV social isolation has been constant throughout their life regardless of age [12, 13] driven by AIDS driven stigma [14, 15]. This social isolation is manifested in the fact that most of older adults with HIV live alone (mean age less than 60) [16-19] .
There is evidence that positive sexual health protects against those stresses that arise from chronic illness that characterizes ageing  . This observation has been often seen in HIV discordant couples [21, 22]. Research supports the view that a gay couple’s sexual health is a function of the quality of their overall relationship. That relationship, and not social perceptions or approval, are correlated with positive sexual satisfaction [7, 23, 24]. This can be a significant issue for those living with HIV. Studies  found that about half of those with HIV report sexual problems which include sexual dissatisfaction. This is not unexpected since sexual dissatisfaction within couple relationships occurs in the presence of chronic illnesses – HIV being one of those chronic illnesses .
Poor quality of life can significantly affect medication adherence as well as patient directed health care decisions that are an integral part of multimorbidity management. Sexual dysfunction can be a side effect of medications , be associated with a past medical/surgical history, or, sexual abuse as well as the oppressive effects of stigma . The successful integration of sexual health care can decrease morbidity and mortality, and enhance well-being and longevity in the patient .
STI Risk in Older Adults with HIV
Health-care professionals more often underestimate the desire for and level of sexual activity in the older adult population thereby neglecting their risk for STI exposure . In fact, CDC reports that STI diagnoses in those 65 years and older are increasing and similar to trends in the 20-24-year-old age group . Quite simply most do not believe that older adults, and especially older adults with HIV, are sexually active. This failure to engage the older adult, and particularly the older adult living with HIV in a conversation about sexual health and the need for safe sex practices has consequences, which include the spread of HIV and other STIs (See Chapter 7 on Detection and Screening for HIV in Older Adults in this series). By not engaging the older adult, medical care providers have been reinforcing the myth that older adults do not have sex. One of the consequences of this prevailing attitude is that with increasing age the likelihood of having an AIDS diagnosis at the time of initial HIV detection increases . Primary prevention for HIV and STI’s in older adults should be a priority for the medical team. Unless identified and addressed the sexual health of the older HIV+ patient will have a negative impact on health outcomes. As well, secondary prevention to minimize HIV transmission is needed.
Sexual Behavior in Older Adults with HIV/AIDS
Detailed studies have begun to examine sexual behavior in older adults living with HIV/AIDS [30-37]. The frequency of unprotected insertive sex is high among older adults with HIV [31, 34]. About 41% of the sexually active older adults with HIV in the ROAH Study report unprotected anal or vaginal sex in the past 3 months [16, 30, 31]. Different frequencies and patterns of sexual risk behavior have been found among older HIV infected adults by gender and sexual orientation. As an example, older HIV- infected men (regardless of sexual orientation) are more likely to be sexually active compared to women, but condom use rates are lowest among gay and bisexual self-identified males, compared to heterosexuals [31, 33]. Studies have also found that older women are at higher risk of STI because of vaginal atrophy that may contribute to increased exposure . Older post-menopausal women may perceive the elimination of the risk for pregnancy as extending to the elimination of the risk for STIs including HIV. As older adults living with HIV begin to internalize the emerging consensus that a low or non-detectable viral load is commensurate with low infectivity (but not zero) they are likely to engage in more sexual risk sex behaviors, avoiding the need to disclose their status and not use a condom . Also, reports suggest that for various reasons, older MSM have paired with younger MSM, thereby increasing risk . Such increased behavioral risk needs to be discussed at regular visits with appropriate counseling given . However, for persons continuing such behavior referral to a program that offers behavioral modification strategies, including group and phone interventions are needed as well as the adoption of PrEP [40-42]. (See Chapter 28 on PrEP and Older Adults in this series)
CDC surveillance data  show that 17% (1 in 6) of all new HIV infections occur at age 50 and older in the US. That incidence rate has increased from 11% in 2002 . Between 30-40% of sexually active HIV infected adults report unprotected anal or vaginal intercourse [30, 31]. Such risk-taking may be associated with less knowledge about HIV/AIDS and recent substance use. Condom use is effective in preventing HIV and STI transmission. However, older persons may not use condoms because they are unaware of the risks. Also, older men can suffer from some degree of erectile dysfunction, which makes condom use less reliable. Topical microbicides for vaginal and anal use by women and men are being developed. Studies show that treatment of an HIV-infected partner in HIV discordant couples reduces significantly the rates of sexual transmission of HIV [44-47].
Studies consistently demonstrate associations between unprotected sex and negative affect, including depression and anxiety. Research finds high levels of depression, loneliness, anxiety, and chronic stress across gender, race/ethnicity, and sexual orientation among older adults with HIV [48-51]. Distress and mental health problems emerge as critical determinants of risk behavior among HIV infected older adults. (See Chapter 7 in this series Detection and Screening for HIV in Older Adults).
A recent exhaustive report on HIV Prevention and Older Adults prepared as part of the New York State Ending AIDS by 2020 effort provides detailed analyses of prevention efforts as well as detailed implementation suggestions and strategies for every community and environment .
How to Talk to Older Adults about Sexual Health: Taking A Sexual Health History
NIH’s National Institute on Aging provides suggestions as to how to initiate conversations regards sexual health with older adults . For the practitioner, taking a sexual health history is essential. The following are examples of elements in taking such a history .
- Do you have any questions or concerns about your sexual functioning? (open ended question)
- Have you noticed any problems or changes with your ability to have or enjoy sex?
- Has your present illness (or medications) affected your sexual function?
- Do you ever have pain with intercourse?
- Women: Do you have any difficulty achieving orgasm?
- Men: Do you have any difficulty obtaining and maintaining an erection? Difficulty with ejaculation?
- Do you have, or have you ever had, any risk factors for HIV? (List blood transfusions, needle stick injuries, IV drug use, STDs, partners who may have placed you at risk, exchanging money for sexual activity, use of alcohol or drugs in association with sexual activity)
- Have you ever had any sexually related diseases?
- What do you do to protect your partner from contracting HIV?
- Do you or your partner use condoms? Always? Sometimes? or Never?
In a 2017 publicartion geriatrics fellows reported inconsistent sexual history taking with older adults. The need to include sexual health content in geriatrics trainings was clear. The encountered barriers included competing competencies, lack of educational materials, and discomfort with this topic .
Stephen Karpiak PhD
New York University
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