Never Too Old -- for Sex or AIDS

There Is No Age Exemption for Safe Sex, but Seniors Are Not Getting the Message

Lou Constantine is 55 years old, single and -- like many people his age -- sexually active. The Germantown resident is also typical of 50-plus singles in another way: He doesn't practice safe sex and doesn't think he needs to. Like many sexually active seniors, he doesn't think he's at risk for HIV.

Constantine is nevertheless part of the one of the country's fastest-growing AIDS demographics -- heterosexuals 50 and older.

For most of the 20 years since the start of the AIDS epidemic, people 50 and over have accounted for a steady 10 percent of all new AIDS cases diagnosed annually. But a few years ago, that rate began an ominous climb -- to 11.6 percent in 1997, 12.7 percent in 1998 and 13.4 percent in 1999, according to the U.S. Centers for Disease Control and Prevention (CDC).

The fastest-rising route of transmission in this age group is nothing exotic like needle use -- it's heterosexual sex. A 1996 CDC breakdown -- the most recent available -- of AIDS cases in individuals 50 or older showed cases transmitted heterosexually increased 94 percent in men and 106 percent in women between 1991 and 1996.

While the number of cases remains relatively small -- 1,400 heterosexual AIDS cases diagnosed nationally among those 50 and older in 1996, up from 700 in 1991 -- experts say those numbers don't tell the whole story. Because seniors are less likely than others to get tested for HIV, many observers are worried that the problem may be larger than the numbers suggest -- and still growing.

Concerned, two federal agencies have launched an initiative to study the problem; two Florida counties are conducting public education programs and two more are planning to join them; and a group called the National Association of HIV Over Fifty (NAHOF) fields questions on its Web site and gives dozens of presentations each year.

The growth of HIV among seniors is also forcing public health officials to rethink attitudes about the elderly. One of the first ideas to go is the wishful notion that seniors are not at risk for HIV because the only thing they do in bed is sleep. Seniors -- mirabile dictu -- are having sex and many either don't know the modern rules of sexual engagement or

don't think the rules apply to them. The last time many of them dated, there was no human immunodeficiency virus, no AIDS.

Dating seniors are often widowed or divorced after decades in one relationship. With many men newly able, thanks to Viagra, and their female partners well past worrying about pregnancy, many forgo condoms. According to a 1994 study published in the Archives of Internal Medicine, one of very few done on this population, about 10 percent of Americans over 50 have at least one HIV risk factor -- such as sex with multiple partners -- and most of those 10 percent don't consistently use condoms during sex.

If many seniors believe HIV is only a young person's disease, it's not surprising. They've seen the public warnings to drug users, gay men, prostitutes, teens, Hispanics and blacks about HIV risks. But there's never been a national education campaign telling seniors -- particularly heterosexual seniors -- they're at risk. So, like Constantine, many figure they aren't.

Worrying that continued ignorance or complacency could spell trouble for the senior community, public health officials are beginning to target more resources for public awareness and new studies of seniors and AIDS. But some critics wonder if the response is a case of too little and very late.

HIV among seniors "is a real concern . . . and there's reason to think it could become more of a problem," says Helene Gayle, director of the CDC's National Center for HIV, STD and TB Prevention. "There is a need to make sure people are more aware of the issue. I definitely think more can be done to get information to this population."

Imaginary Immunity

It's a fact: Because most at-risk seniors -- including those with multiple sex partners, those who have had a blood transfusion between 1979 and 1985, and anyone whose partner has a known behavioral risk -- don't think they are hazarding infection, most don't get tested for HIV. The 1994 Archives of Internal Medicine study found this held true for 90 percent of at-risk seniors -- making them one-fifth as likely to get tested compared to at-risk individuals in their twenties.

Because so few seniors have been tested, it's hard to know how many are infected -- and how many are unwittingly passing the virus on to others.

"Nobody knows what's going on with the older adult," says Joseph Catania of the University of California at San Francisco, one of the country's leading AIDS researchers and co-author of the 1994 study.

Even when seniors develop AIDS-related symptoms like wasting, dementia and pneumonia, doctors frequently don't think to test them for HIV. "It is clear from a number of recent studies that older patients may not be tested for HIV as often as younger persons, based on the mistaken belief that they are not at risk," says David Rimland, chief of infectious diseases for the Atlanta VA Medical Center. "These patients will continue to potentially transmit the virus until they are diagnosed."

Seniors themselves often assume their AIDS-related symptoms are simply part of the aging process. "The older person says, 'Well, all my friends have aches and pains,' " says AIDS researcher Amy Justice, staff physician at the VA Pittsburgh Healthcare System.

Agrees Courtney Williams, community planner for the D.C. Office on Aging and coordinator of the District's HIV/AIDS programs, "There are a lot of [infected seniors] out there you don't hear about. It's hush-hush. . . . Nobody questions, 'Oh, Mrs. Such-and-Such was 70 and died of pneumonia.' Nobody ever thinks maybe it was AIDS."

Constantine says he sees five or six women a year, and has sex with two or three. And, like many dating seniors, he rarely uses condoms.

"If you ask me why I don't, I can't really give you a substantial answer," he says. "Maybe I just feel like I'm not vulnerable. That I'm not at risk. I think most [seniors] don't feel that they're at risk. I realize there's a chance I could get sick, but I think it's minimal. The chance of me coming down with AIDS is about the same as me winning the lottery."

Jane Fowler of Kansas City, Mo., and Sue Saunders and Cheryl Barker of Fort Lauderdale, Fla., once thought that way, too. Then, when they were all 50 or older, they learned they were HIV-positive. Fowler and Saunders say they contracted the virus from men they were dating. Barker says she got it from her husband.

"I wanted to believe it couldn't happen to me, that it happened to people who were younger and were having sex with multiple partners," says Barker, 56. "I was dumb to the facts of HIV."

Sex and the Senior Citizen

Society makes a lot of erroneous assumptions about old people -- one is that sex stops somewhere around 60.

Sexual behavior surveys suggest something else. According to a 1999 survey sponsored by AARP, one-third of men and one-fourth of women ages 60 to 74 have sex at least once a week.

Seniors are having sex, and "lots of it, whenever they want it," says Lisa Agate, HIV/AIDS program director at the Broward County Health Department in Florida, which holds safe sex seminars for older residents. In retirement communities, she says, people have time on their hands, and a man of 70 or 80 who can still drive is viewed as "a hot commodity."

Saunders agrees. "If a man can drive at night, ooh man, he's got every woman he wants," says Saunders, who was diagnosed HIV-positive 10 years ago when she was 58 and now conducts HIV workshops for seniors through Agate's program. "I've met lots of guys who have seven girlfriends. [The women] don't care, because they're so lonely," she says.

Studies offer some support for such accounts -- though they tend to focus on the younger segment of this age group.

National surveys analyzed in "The Social Organization of Sexuality: Sexual Practices in the United States," a 1994 text published by the University of Chicago Press, found that among formerly married men age 45 to 59, 45 percent reported one partner and 25 percent had two or more partners. Among former married women of the same age, 36 percent reported one sex partner and 10 percent had two or more partners. Having more than one sexual partner in 12 months is considered an HIV risk factor.

Higher levels of promiscuity may turn up in some individuals and in some communities, but they are not the norm, says book co-author Robert Michael, dean of the Harris School of Public Policy at the University of Chicago. "There's not a lot of multiple partnering," says Michael.

But just because you're not sexually promiscuous doesn't mean you're exempt from risk. Seniors "are careless," says Vinod Mody, chief of infectious diseases at Howard University Hospital. "They are not having safe sex. They do not think they might get HIV. This age group somehow has to be educated."

"It's as though once somebody is middle-aged, they think they are immune from getting a sexually transmitted disease," says Marcia Ory, chief of behavioral medicine and public health at the National Institute on Aging. "You are not immune. If you are exposed, you are likely to get infected."

Overdue Attention

When Amy Justice first began studying HIV in seniors in 1996, other researchers thought her choice of topic a little esoteric. Even a committee at the National Institute on Aging (NIA) that reviewed her request for funding expressed doubt. "The first set of responses I got was, 'Why should the NIA be interested HIV?' " she recalls.

That's changing. "In the last five years, I've had a lot of people come up to me and say, 'You know, you've got a point,' " she says. Now, Justice is a lead researcher on one of the first large-scale studies of seniors with HIV; her results will shed light on many of the unknowns about how the disease affects the elderly.

And while the government spends relatively little studying seniors with HIV, funding for such research is increasing this year: NIA and the National Institute of Mental Health are jointly allotting a total of up to $1.5 million for the first national initiative to look specifically at HIV prevention and intervention in seniors, says Ory.

"There's a lot of speculation about what's going on" sexually in the older population and "a lot of speculation about the impact of Viagra," she says. "There's been no careful study. Very little money has been devoted to research for the 50-plus population. It is just a topic that is totally neglected."

Research is key, educators say, because until you know exactly what people are doing and what their attitudes are toward sex and HIV, it's hard know how best to deliver the safe sex message.

Other glimmers of change:

• More conferences lately are focusing on seniors and HIV. The District's Office on Aging and Department of Health sponsored a June conference on seniors and HIV and a Florida conference on African Americans' health care issues, also in June, dedicated a whole day to HIV and seniors.

• NAHOF's fourth annual conference in June got "incredible response," says Jane Fowler, an HIV-infected senior who helps run the organization. About 50 researchers expressed interest in presenting papers, she says. "Considering that a few years ago there was nothing, I think it's phenomenal."

• More cities and counties nationwide are launching HIV/AIDS programs like Broward County's. In Florida alone, three counties are following Broward's lead by launching HIV education and prevention programs aimed at seniors. "For 10 years, NIA has been calling attention to this issue," says Ory. "For whatever reason, within the last six months there has been a lot more public awareness."

But many say changes are coming too slowly. "We still have a long way to go. Folks still see the face of AIDS as a young face," says Diane Zablotsky, an associate sociology professor at the University of North Carolina, Charlotte.

While agencies are doing more than they used to, "you can say we probably are not doing as much as we should, and probably too little, too late," says Thomas Obisesan, chief of Howard University Hospital's geriatrics department and medical director for the Washington Center for Aging Services, a 262-bed nursing home.

"Physicians in general are not as sensitive as they should be to the issue of HIV in seniors," Obisesan says. The consequence of continued failure to educate doctors and seniors, he says, "is going to be very, very significant."

Fowler, a founder of NAHOF who has given more than 400 talks on the subject, says that while some people are waking up to the problem, most still are just not getting it. "Too many in the older population don't realize what's out there, and they don't realize that they are at risk," she says.

Fowler says she still has a hard time getting some groups to even put her on their conference schedules -- they just don't think the issue is key. At a recent medical conference, she says, half the crowd -- about 75 people -- got up and left as she stood to take her turn at the podium.

Still, she persists, telling anyone who will listen how she was infected by a friend she dated after her divorce. After Fowler's talk to students a few years ago at the University of Kansas, she says, a woman in the audience stood and said, " 'I'm about your age. I had some intimacies after my divorce. I'm sitting here thinking, 'There but for the grace of God go I.' "

Replied Fowler, " 'Well, have you been tested?' She just gulped. It still didn't occur to her that if she had done what I did, she'd better get tested.

"It's still a disease of 'them,' not us. It's, 'Oh, so Jane Fowler got infected. Too bad. It happened to her, not me.' Well, anybody who is having sex is putting himself or herself at risk for HIV. This can happen to anybody."

Michelle Nicolosi is a freelance medical writer in Seattle.