Attitudes and stereotypes regarding older women and HIV risk

Older persons' knowledge of HIV and AIDS prevention in a province of South Africa

BACKGROUND

 Population ageing and access to antiretroviral therapy have resulted in an increase in the proportion of older people living with human immunodeficiency virus (HIV). However, scant knowledge is available to inform the design of educational programmes to target these persons in low- and middle-income countries.

AIM

 This study aimed to examine how persons aged ≥ 50 years view their risk of contracting HIV, and the extent to which they are supported in preventing infection and are impacted by the HIV or acquired immune deficiency syndrome (AIDS) epidemic.

SETTING

 Rural sites in the Western Cape Province of South Africa.

METHODS

 This study followed a qualitative design. Two focus group discussions with persons aged ≥ 50 years and interviews with two key informants were conducted at seniors' centres. Discussions were digitally audio recorded and the recordings were transcribed, and data were thematically analysed.

RESULTS

 Overall, awareness of the risk of older persons contracting HIV infection in this population was poor. Stigmatisation of the disease in the community and at health care facilities affected individuals' willingness to be tested for the virus and/or to disclose their status, if positive. Participants viewed HIV and AIDS education programmes as focussed on the youth and educational sessions for large groups were not helpful in stemming the epidemic.

CONCLUSION

 Dissemination of information on older persons' vulnerability to the disease, and education on HIV and AIDS tailored for and targeted at this age group have been relatively neglected.Contribution: Educational programmes on HIV, as well as productive channels and platforms to target older populations, particularly those with a low health literacy level are required.

Non-pharmacological interventions for the prevention of sexually transmitted infections (STIs) in older adults: A systematic review

BACKGROUND

STIs in older adults (adults aged 50 years and older) are on the rise due to variable levels of sex literacy and misperceived susceptibility to infections, among other factors. We systematically reviewed evidence on the effect of non-pharmacological interventions for the primary prevention of sexually transmitted infections (STIs) and high-risk sexual behaviour in older adults.

METHODS

We searched EMBASE, MEDLINE, PSYCINFO, Global Health and the Cochrane Library from inception until March 9th, 2022. We included RCTs, cluster-randomised trials, quasi-RCTs, interrupted time series (ITS) and controlled and uncontrolled before-and-after studies of non-pharmacological primary prevention interventions (e.g. educational and behaviour change interventions) in older adults, reporting either qualitative or quantitative findings. At least two review authors independently assessed the eligibility of articles and extracted data on main characteristics, risk of bias and study findings. Narrative synthesis was performed.

RESULTS

Ten studies (two RCTs, seven quasi-experiment studies and one qualitative study) were found to be eligible for this review. These interventions were mainly information, education and communication activities (IECs) aimed at fostering participants' knowledge on STIs and safer sex, mostly focused on HIV. Most studies used self-reported outcomes measuring knowledge and behaviour change related to HIV, STIs and safer sex. Studies generally reported an increase in STI/HIV knowledge. However, risk of bias was high or critical across all studies.

CONCLUSIONS

Literature on non-pharmacological interventions for older adults is sparse, particularly outside the US and for STIs other than HIV. There is evidence that IECs may improve short-term knowledge about STIs however, it is not clear this translates into long-term improvement or behaviour change as all studies included in this review had follow-up times of 3 months or less. More robust and higher-quality studies are needed in order to confirm the effectiveness of non-pharmacological primary prevention interventions for reducing STIs in the older adult population.

Interest in Long-Acting Injectable Pre-exposure Prophylaxis (LAI PrEP) Among Women in the Women's Interagency HIV Study (WIHS): A Qualitative Study Across Six Cities in the United States

Long-acting injectable (LAI) pre-exposure prophylaxis (PrEP) has the potential to facilitate adherence and transform HIV prevention. However, little LAI PrEP research has occurred among women, who face unique barriers. We conducted 30 in-depth interviews with HIV-negative women from 2017-2018 across six sites (New York; Chicago; San Francisco; Atlanta; Washington, DC; Chapel Hill) of the Women's Interagency HIV Study. Interviews were recorded, transcribed, and analyzed using thematic content analysis. Few women expressed interest in PrEP and when prompted to choose a regimen, 55% would prefer LAI, 10% daily pills, and 33% said they would not take PrEP regardless of formulation. Perceived barriers included: (1) the fear of new-and perceived untested-injectable products and (2) potential side effects (e.g., injection-site pain, nausea). Facilitators included: (1) believing shots were more effective than pills; (2) ease and convenience; and (3) confidentiality. Future studies should incorporate women's LAI PrEP-related experiences to facilitate uptake.

Older African Americans and the HIV Care Continuum: A Systematic Review of the Literature, 2003-2018

Evidence suggests that racial disparities in the HIV care continuum persist in older age groups, particularly among African Americans. The objective of this systematic review was to identify factors that facilitate or hinder older African Americans' engagement in the HIV care continuum. For studies published between 2003 and 2018, we: (1) searched databases using keywords, (2) excluded non-peer-reviewed studies, (3) limited findings to older African Americans and the HIV care continuum, and (4) retrieved and summarized data focused on barriers and facilitators of the HIV care continuum. Among the 1023 studies extracted, 13 were included: diagnosis/testing (n = 1), engagement in care (n = 7), and antiretroviral adherence (n = 5). Barriers included lack of HIV risk awareness, routine testing, and healthcare access, stigma, and multimorbidities. Social support, health/medication literacy, and increased self-efficacy facilitated engagement. A targeted focus on older African Americans is needed to achieve national goals of improving HIV care and treatment outcomes.

Dysregulation in Genital Tract Soluble Immune Mediators in Postmenopausal Women Is Distinct by HIV Status

A rise in new HIV diagnoses among older adults is characterized by poor prognosis and reduced survival times. Although heterosexual transmission remains the main route of infection in women, little is known regarding immune functions in the genital tract of postmenopausal women, especially those who are HIV positive. Furthermore, effects of hormone replacement therapy (HRT) on the genital tract immune system are unclear. Using the Women's Interagency HIV Study repository, we obtained cervical-vaginal lavage (CVL) samples from premenopausal and postmenopausal HIV-positive and HIV-negative women, some of whom were on HRT. Samples were assayed for interleukin (IL)-6, IL-8, tumor necrosis factor (TNF)-α, secretory leukocyte protease inhibitor (SLPI), Elafin, human beta defensin-2 (HBD2), and macrophage inflammatory protein (MIP)-3α using ELISA. Anti-HIV activity in CVL was measured using TZM-bl indicator cells. Among HIV-positive women, the plasma viral load was significantly higher and CD4 count was significantly lower in postmenopausal compared with premenopausal women. Postmenopausal women, irrespective of HIV status, had significantly lower levels of HBD2 compared with premenopausal women. Among the HIV-negative individuals, postmenopausal women had significantly lower levels of MIP-3α, IL-6, and SLPI compared with premenopausal women. In contrast, HIV-positive postmenopausal women had significantly higher levels of TNF-α compared with HIV-positive premenopausal women. In most cases, HRT groups resembled the postmenopausal groups. No significant differences in anti-HIV activity by menopausal or by HIV status were noted. Our findings indicate that the female genital tract immune microenvironment is distinct by menopausal status and HIV status. Further studies are needed to assess the risk of HIV acquisition/transmission in this population.

“I Don’t Know and I Don’t Want to Know”: A Qualitative Examination of Older African American Women’s Knowledge and Experiences With HIV

While older African American women (e.g., aged 50 years and older) comprise only 11% of the female population in the United States, they account for 50% of HIV diagnoses among women in this age group. Unique sociocultural factors, including a lack of HIV knowledge and stigma, contribute to HIV risk among older African American women. The goal of this qualitative study was to obtain a nuanced perspective from older African American women about HIV knowledge and experiences with HIV using the framework of intersectionality theory. Focus groups were conducted with 35 African American women who were 50 years and older, nonpartnered, and heterosexual. Women were asked what they knew about HIV and if they thought older women were at risk for HIV. A thematic analysis using NVivo 11 yielded two central themes and three subthemes: HIV knowledge, including experiential knowledge, superficial knowledge, and no knowledge, and stigma around HIV in the Black church. Implications for developing HIV prevention programs and testing messages are discussed.

Risk and protective factors of posttraumatic stress disorder among African American women living with HIV

We sought to examine risk and protective factors for Posttraumatic Stress Disorder (PTSD) among African American women living with HIV. This is a cross-sectional analysis of baseline data from a randomized trial of an HIV stigma reduction intervention. We examined data from two-hundred and thirty-nine African American women living with HIV. We examined whether age, marital status, level of education, internalized HIV-related stigma, and social support as potential protective and risk factors for PTSD symptoms using logistic regression. We analyzed bi-variate associations between each variable and PTSD symptoms, and constructed a multivariate logistic regression model adjusting for all variables. We found 67% reported clinically significant PTSD symptoms at baseline. Our results suggest that age, education, and internalized stigma were found to be associated with PTSD symptoms (p < 0.001), with older age and more education as protective factors and stigma as a risk factor for PTSD. Therefore, understanding this relationship may help improve assessment and treatment through evidence- based and trauma-informed strategies.

Women 50 and Older and HIV: Prevention and Implications for Health Care Providers

The current article discusses the importance of implementing HIV and AIDS education, prevention, and intervention programs that are tailored to women 50 and older and to determine HIV risk factors for this population. A literature search was performed, resulting in 41 relevant articles. The literature underscored the significance of increasing awareness of HIV/AIDS, particularly among older women. HIV risk behaviors and the effect that these behaviors have on HIV transmission and prevention among women 50 and older are described. Prior research findings identified risk categories of older women that may contribute to the transmission of HIV among this particular population, including heterosexual relations, perceived HIV risk, ageism and HIV transmission, biological factors, transfusions, sexual enhancement aids, and health care providers and prevention messages. In addition, previous findings indicate that health care providers have not traditionally targeted women 50 and older for HIV prevention. Health care providers should incorporate discussion of HIV risk and transmission during clinic visits and implement prevention programs that target this population. [Journal of Gerontological Nursing, 43(12), 29-34.].

Resilience in low-income African American women living and aging with HIV

Women are living with HIV into middle and older age and are likely to face multiple comorbidities and stressors as they age. This study focused on understanding how women who experience multiple forms of oppression and ongoing adversity are still able to adapt and stand strong. Using a theoretical framework of resilience and a feminist research ideology, interviews of eight middle-aged and older African American women living with HIV were analyzed. Despite experiences of HIV-related discrimination, trauma, and violence, these women demonstrated a remarkable ability to adapt and maintain support. Implications for research and practice are discussed.

Social exclusion of older persons: a scoping review and conceptual framework

As a concept, social exclusion has considerable potential to explain and respond to disadvantage in later life. However, in the context of ageing populations, the construct remains ambiguous. A disjointed evidence-base, spread across disparate disciplines, compounds the challenge of developing a coherent understanding of exclusion in older age. This article addresses this research deficit by presenting the findings of a two-stage scoping review encompassing seven separate reviews of the international literature pertaining to old-age social exclusion. Stage one involved a review of conceptual frameworks on old-age exclusion, identifying conceptual understandings and key domains of later-life exclusion. Stage two involved scoping reviews on each domain (six in all). Stage one identified six conceptual frameworks on old-age exclusion and six common domains across these frameworks: neighbourhood and community; services, amenities and mobility; social relations; material and financial resources; socio-cultural aspects; and civic participation. International literature concentrated on the first four domains, but indicated a general lack of research knowledge and of theoretical development. Drawing on all seven scoping reviews and a knowledge synthesis, the article presents a new definition and conceptual framework relating to old-age exclusion.

Reduced levels of genital tract immune biomarkers in postmenopausal women: implications for HIV acquisition

BACKGROUND

Rates of HIV infections are increasing in older adults. Although it is known that the HIV/AIDS epidemics affects women disproportionately, little is known regarding immune functions in the genital tract of postmenopausal women, as relevant to HIV susceptibility.

OBJECTIVE

The objective of the study was to compare levels of female reproductive tract immune mediators that are important for HIV-associated immune responses as well as intrinsic anti-HIV activity in the cervical vaginal lavages collected from HIV-negative pre- and postmenopausal women.

STUDY DESIGN

Cervical vaginal lavage from 20 premenopausal and 20 postmenopausal women were assayed for interleukin-6, interleukin-8, tumor necrosis factor-α, secretory leukocyte protease inhibitor, elafin, human β-defensin-2, and macrophage inflammatory protein-3α using standard enzyme-linked immunosorbent assays. Anti-HIV activity of cervical-vaginal lavage was measured using TZM-bl indicator cells against HIV-1 IIIB and BaL. Whereas each postmenopausal woman provided only 1 sample, each premenopausal woman provided 3 samples, during proliferative, ovulatory, and secretory stages, based on menstrual dates.

RESULTS

We observed significantly lower levels of tumor necrosis factor-α, MIP-3α, secretory leukocyte protease inhibitor, elafin, and human β-defensin-2 in cervical vaginal lavage from postmenopausal women compared with premenopausal women. Inhibition of HIV-1 infection was observed for both pre- and postmenopausal women, but cervical vaginal lavage from postmenopausal women showed significantly higher inhibition against HIV-1 BaL after adjusting for total protein concentration, genital pH, and reproductive tract infections. No change in mediators or HIV inhibition was observed through the stages of menstrual cycle. In addition, we observed that postmenopausal women with reproductive tract infections had significantly higher levels of tumor necrosis factor-α and significantly lower levels of interleukin-8, which were not observed in premenopausal women.

CONCLUSION

Our findings suggest that female reproductive tract immune microenvironment is distinct in HIV-negative postmenopausal women. Further studies are needed to assess the risk of HIV acquisition/transmission in this population.

Shifting the HIV Training and Research Paradigm to Address Disparities in HIV Outcomes

Tailored programs to diversify the pool of HIV/AIDS investigators and provide sufficient training and support for minority investigators to compete successfully are uncommon in the US and abroad. This paper encourages a shift in the HIV/AIDS training and research paradigm to effectively train and mentor Latino researchers in the US, Latin America and the Caribbean. We suggest three strategies to accomplish this: (1) coaching senior administrative and academic staff of HIV/AIDS training programs on the needs, values, and experiences unique to Latino investigators; (2) encouraging mentors to be receptive to a different set of research questions and approaches that Latino researchers offer due to their life experiences and perspectives; and (3) creating a virtual infrastructure to share resources and tackle challenges faced by minority researchers. Shifts in the research paradigm to include, retain, and promote Latino HIV/AIDS researchers will benefit the scientific process and the patients and communities who await the promise of HIV/AIDS research.

Midlife and older women's experiences and advice about sex with men, risk behaviors, and HIV prevention education

This article reports on older women's experiences and advice on condom use, male-female relationships, HIV risk, and prevention education. It reports on findings from five written, open-ended questions with 110 ethnically and economically diverse women, 40-80 years old. Analysis revealed four themes: (a) Gap between condom use advice and condom use behavior; (b) invisibility with age; (c) negative expectations of men; and (d) desire for education that breaks the silence on sex. The article discusses the meaning of the findings as they relate to current knowledge about HIV prevention education and midlife and older women and offers recommendations for research and education.

Sexual protective strategies and condom use in middle-aged African American women: a qualitative study

The heterosexual transmission of HIV has affected middle-aged African American women at alarming rates; yet there is a paucity of research and interventions focused on this population. This study used a qualitative approach to understand middle-aged urban African American women's experiences with HIV-related sexual risk behaviors and to identify the sexual protective strategies they employed to reduce their risk for HIV infection. Ten African American women, ages 45 to 56 years, were recruited from low-income neighborhoods in New York City. Data were collected using in-depth interviews and analyzed using content analysis. Investigator triangulation and member checking were used to ensure rigor. Five salient themes emerged that highlighted the individual, gender/relationship power factors, and the sociocultural elements that influenced sexual protection or risk-taking behavior. Findings provide new insight into the complexities of HIV sexual risk behavior and can guide future HIV prevention interventions for middle-aged, African American, urban women.

Sexual risk behaviors and HIV risk among Americans aged 50 years or older: a review

Although HIV-related sexual risk behaviors have been studied extensively in adolescents and young adults, there is limited information about these behaviors among older Americans, which make up a growing segment of the US population and an understudied population. This review of the literature dealing with sexual behaviors that increase the risk of becoming HIV-infected found a low prevalence of condom use among older adults, even when not in a long-term relationship with a single partner. A seminal study by Schick et al published in 2010 reported that the prevalence of condom use at last intercourse was highest among those aged 50–59 years (24.3%; 95% confidence interval, 15.6–35.8) and declined with age, with a 17.1% prevalence among those aged 60–69 years (17.1%; 95% confidence interval, 7.3–34.2). Studies have shown that older Americans may underestimate their risk of becoming HIV-infected. Substance use also increases the risk for sexual risk behaviors, and studies have indicated that the prevalence of substance use among older adults has increased in the past decade. As is the case with younger adults, the prevalence of HIV infections is elevated among ethnic minorities, drug users (eg, injection drug users), and men who have sex with men. When infected, older adults are likely to be diagnosed with HIV-related medical disorders later in the course of illness compared with their younger counterparts. Physicians are less likely to discuss sexual risk behaviors with older adults and to test them for HIV compared with younger adults. Thus, it is important to educate clinicians about sexual risk behaviors in the older age group and to design preventive interventions specifically designed for older adults.