Sexual Health in HIV and Aging (Updated 10/16/17)

  • 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 [4] 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 [5]. Lindau’s seminal USA data [1] 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 [6]. 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 [20] . 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 [25] 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 [26].

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 [27], be associated with a past medical/surgical history, or, sexual abuse as well as the oppressive effects of stigma [28]. The successful integration of sexual health care can decrease morbidity and mortality, and enhance well-being and longevity in the patient [26].

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 [1]. 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 [29]. 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 [8]. 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 [1]. 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 [38]. Also, reports suggest that for various reasons, older MSM have paired with younger MSM, thereby increasing risk [39]. Such increased behavioral risk needs to be discussed at regular visits with appropriate counseling given [40]. 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 [43] 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 [43]. 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 [8].

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 [52]. For the practitioner, taking a sexual health history is essential. The following are examples of elements in taking such a history [53].

  • 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[54] 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 [54].

Updated 9/2017

Stephen Karpiak PhD

New York University


  1. Lindau ST, Schumm LP, Laumann EO, Levinson W, O’Muircheartaigh CA, Waite LJ. A study of sexuality and health among older adults in the United States. N Engl J Med 2007; 357(8):762-774.
  2. Liu H, Waite LJ, Shen S, Wang DH. Is Sex Good for Your Health? A National Study on Partnered Sexuality and Cardiovascular Risk among Older Men and Women. J Health Soc Behav 2016; 57(3):276-296.
  3. Allen MS, Desille AE. Personality and sexuality in older adults. Psychol Health 2017; 32(7):843-859.
  4. Wang V, Depp CA, Ceglowski J, Thompson WK, Rock D, Jeste DV. Sexual health and function in later life: a population-based study of 606 older adults with a partner. Am J Geriatr Psychiatry 2015; 23(3):227-233.
  5. Pfizer’s Viagra revenue worldwide 2003-2016. The Statistics Portal. 2017. . 2017.
  6. Taylor TN, Weedon J, Golub ET, Karpiak SE, Gandhi M, Cohen MH, et al. Longitudinal Trends in Sexual Behaviors with Advancing Age and Menopause Among Women With and Without HIV-1 Infection. AIDS Behav 2015; 19(5):931-940.
  7. Taylor TN, Munoz-Plaza CE, Goparaju L, Martinez O, Holman S, Minkoff HL, et al. “The Pleasure Is Better as I’ve Gotten Older”: Sexual Health, Sexuality, and Sexual Risk Behaviors Among Older Women Living With HIV. Arch Sex Behav 2016.
  8. Committee. NEW YORK STATE ENDING THE EPIDEMIC: Older Adults (50+) and HIV. In; 2016.
  9. DeLamater J, Koepsel E. Relationships and sexual expression in later life: a biopsychosocial perspective. Sexual and Relationship Therapy 2014.
  10. Taylor JM, Munoz A, Kingsley LA, Chmiel JS, Saah AJ. Two quick estimates of the HIV prevalence in homosexual men in Los Angeles, New York and San Francisco. The Multicenter AIDS Cohort Study. AIDS 1990; 4(9):921-922.
  11. Andany N, Kennedy VL, Aden M, Loutfy M. Perspectives on menopause and women with HIV. Int J Womens Health 2016; 8:1-22.
  12. Greysen SR, Horwitz LI, Covinsky KE, Gordon K, Ohl ME, Justice AC. Does social isolation predict hospitalization and mortality among HIV+ and uninfected older veterans? J Am Geriatr Soc 2013; 61(9):1456-1463.
  13. Cattan M, White M, Bond J, Learmouth A. Preventing social isolation and loneliness among older people: a systematic review of health promotion interventions. Ageing and Society 2005; 25(01):41-67.
  14. Older people with HIV face stigma. Nurs Older People 2017; 29(2):6.
  15. Baugher AR, Beer L, Fagan JL, Mattson CL, Freedman M, Skarbinski J, et al. Prevalence of Internalized HIV-Related Stigma Among HIV-Infected Adults in Care, United States, 2011-2013. AIDS Behav 2017:1-9.
  16. Brennan M, Karpiak SE, Shippy RA, Cantor MJ. Older adults with HIV: An in-depth examination of an emerging population. Nova Science Publishers, Inc.; 2011.
  17. Brennan DJ, Emlet CA, Brennenstuhl S, Rueda S. Socio-demographic Profile of Older Adults with HIV/AIDS: Gender and Sexual Orientation Differences. Canadian Journal on Aging 2013; 32(1):31-43.
  18. Shippy RA, Karpiak SE. Perceptions of Support Among Older Adults With HIV. Research on Aging 2005; 27(3):290.
  19. Shippy RA, Karpiak SE. The aging HIV/AIDS population: Fragile social networks. Aging & Mental Health 2005; 9(3):246-254.
  20. Ryff C, Singer B. The Contours of Positive Human Health. Psychological Inquiry 1998; 9(1):1–28.
  21. Gamarel KE, Starks TJ, Dilworth SE, Neilands TB, Taylor JM, Johnson MO. Personal or relational? Examining sexual health in the context of HIV serodiscordant same-sex male couples. AIDS and behavior 2014; 18(1):171-179.
  22. Gamarel KE, Neilands TB, Golub SA, Johnson MO. An omitted level: an examination of relational orientations and viral suppression among HIV serodiscordant male couples. Journal of acquired immune deficiency syndromes 2014; 66(2):193-196.
  23. Sprecher SC, R.M. Sexual Satisfaction and Sexual Expressions as Predictors of Relationship Satisfaction and Stability. Handbook of Sexuality in Close Relationships Mahwah: Lawrence Erlbaum Associates Inc 2004.
  24. Berg CA, Upchurch R. A developmental-contextual model of couples coping with chronic illness across the adult life span. Psychological bulletin 2007; 133(6):920-954.
  25. Trotta MP, Ammassari A, Murri R, Marconi P, Zaccarelli M, Cozzi-Lepri A, et al. Self-reported sexual dysfunction is frequent among HIV-infected persons and is associated with suboptimal adherence to antiretrovirals. AIDS Patient Care STDS 2008; 22(4):291-299.
  26. Diamond L, Huebner D. Is Good Sex Good for You? Rethinking Sexuality and Health. Soc Pers Psychol Compass 2012; 6:54-59.
  27. Sewell J, Miltz A, Lampe FC, Cambiano V, Speakman A, Phillips AN, et al. Poly drug use, chemsex drug use, and associations with sexual risk behaviour in HIV-negative men who have sex with men attending sexual health clinics. International Journal of Drug Policy 2017; 43:33-43.
  28. Gesink D, Whiskeyjack L, Suntjens T, Mihic A, McGilvery P. Abuse of power in relationships and sexual health. Child Abuse Negl 2016; 58:12-23.
  29. CDC. Sexually Transmitted Disease Surveillance, 2016. Atlanta: US Department of Health and Human Services 2016.
  30. Golub SA, Botsko M, Gamarel KE, Parsons JT, Brennan M, Karpiak SE. Dimensions of Psychological Well-being Predict Consistent Condom Use among Older Adults Living with HIV. Ageing International 2011; 36(3):346-360.
  31. Golub SA, Tomassilli JC, Pantalone DW, Brennan M, Karpiak SE, Parsons JT. Prevalence and Correlates of Sexual Behavior and Risk Management Among HIV-Positive Adults Over 50. Sexually Transmitted Diseases 2010:1.
  32. Szerlip MA, DeSalvo KB, Szerlip HM. Predictors of HIV-infection in older adults. J Aging Health 2005; 17(3):293-304.
  33. Lovejoy TI, Heckman TG, Sikkema KJ, Hansen NB, Kochman A, Suhr JA, et al. Patterns and correlates of sexual activity and condom use behavior in persons 50-plus years of age living with HIV/AIDS. AIDS and behavior 2008; 12(6):943-956.
  34. Taylor TN, Weedon J, Golub ET, Karpiak SE, Gandhi M, Cohen MH, et al. Longitudinal Trends in Sexual Behaviors with Advancing Age and Menopause Among Women With and Without HIV-1 Infection. AIDS and behavior 2014.
  35. Lovejoy TI, Heckman TG, Sikkema KJ, Hansen NB, Kochman A. Changes in sexual behavior of HIV-infected older adults enrolled in a clinical trial of standalone group psychotherapies targeting depression. AIDS Behav 2015; 19(1):1-8.
  36. Heckman BD, Lovejoy TI, Heckman TG, Anderson T, Grimes T, Sutton M, et al. The moderating role of sexual identity in group teletherapy for adults aging with HIV. Behav Med 2014; 40(3):134-142.
  37. Ompad DC, Giobazolia TT, Barton SC, Halkitis SN, Boone CA, Halkitis PN, et al. Drug use among HIV+ adults aged 50 and older: findings from the GOLD II study. AIDS Care 2016; 28(11):1373-1377.
  38. Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med 2011; 365(6):493-505.
  39. Mustanski B, Newcomb ME. Older sexual partners may contribute to racial disparities in HIV among young men who have sex with men. J Adolesc Health 2013; 52(6):666-667.
  40. Aberg JA, Kaplan JE, Libman H, Emmanuel P, Anderson JR, Stone VE, et al. Primary care guidelines for the management of persons infected with human immunodeficiency virus: 2009 update by the HIV medicine Association of the Infectious Diseases Society of America. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 2009; 49(5):651-681.
  41. Illa L, Echenique M, Jean GS, Bustamante-Avellaneda V, Metsch L, Mendez-Mulet L, et al. Project ROADMAP: Reeducating Older Adults in Maintaining AIDS Prevention: a secondary intervention for older HIV-positive adults. AIDS Educ Prev 2010; 22(2):138-147.
  42. Lovejoy TI, Heckman TG, Suhr JA, Anderson T, Heckman BD, France CR. Telephone-administered motivational interviewing reduces risky sexual behavior in HIV-positive late middle-age and older adults: a pilot randomized controlled trial. AIDS Behav 2011; 15(8):1623-1634.
  43. CDC. Diagnoses of HIV Infection in the United States and Dependent Areas, 2013

HIV Surveillance Report 2014; 25.

  1. Davis T, Zanjani F. Prevention of HIV among older adults: a literature review and recommendations for future research. J Aging Health 2012; 24(8):1399-1420.
  2. CDC. HIV Infection Among Heterosexuals at Increased Risk — United States, 2010. MMWR 2013; 62(10).
  3. Conner LR, Engstrom M, Junious E, Edwards-Knight K. Woman to Woman (W2W): Adapting an HIV risk reduction intervention for older women. J Women Aging 2017:1-16.
  4. Dispenza F, Dew BJ, Tatum AK, Wolf ECM. Sexual Health Risk Behaviors Among Older Men Who Have Sex With Men: Implications for Interventions. Adultspan Journal 2015; 14(1):35-48.
  5. Grov C, Golub SA, Parsons JT, Brennan M, Karpiak SE. Loneliness and HIV-related stigma explain depression among older HIV-positive adults. AIDS Care 2010; 22(5):630-639.
  6. Heckman TG, Kochman A, Sikkema KJ, Kalichman SC, Masten J, Goodkin K. Late middle-aged and older men living with HIV/AIDS: race differences in coping, social support, and psychological distress. J Natl Med Assoc 2000; 92(9):436-444.
  7. Kalichman SC, Heckman T, Kochman A, Sikkema K, Bergholte J. Depression and thoughts of suicide among middle-aged and older persons living with HIV-AIDS. Psychiatr Serv 2000; 51(7):903-907.
  8. Stall R, Mills TC, Williamson J, Hart T, Greenwood G, Paul J, et al. Association of co-occurring psychosocial health problems and increased vulnerability to HIV/AIDS among urban men who have sex with men. American journal of public health 2003; 93(6):939-942.
  9. NIA. Sexuality in Later Life. 2013.
  10. Nusbaum MRHaHCD. The Proactive Sexual Health History. In; 2002. pp. 1705–1712.
  11. Brennan-Ing M, Seidel L, Ansell P, Raik BL, Greenberg D, Nicastri C, et al. Addressing Sexual Health in Geriatrics Education. Gerontol Geriatr Educ 2017.

General Disclaimer: is designed for educational purposes only and is not engaged in rendering medical advice or professional services. The information provided through should not be used for diagnosing or treating a health problem or a disease. It is not a substitute for professional care. If you have or suspect you may have a health problem, consult your health care provider.