By Wendy Bonifazi, RN, CLS, APR, Nursing Spectrum
October 6, 2008
It's important to reinforce the message that anyone, at any age, can pick up sexually transmitted infections, says Tara Barreto, RN, Positive Healthcare's state director of disease management. "Quite often, the older population does not think of safe sex in terms of HIV/AIDS or STD prevention; their 'definition' is preventing pregnancy only. Since they are past childbearing age, use of a condom isn't even a consideration." Unfortunately, as some older Floridians are learning too late, they're at risk. People aged 65 and older made up 0.69% of syphillis cases in 2005, 0.06% of chlamydia cases, and 0.28% of gonorrhea cases.
And although the state has been on the forefront of elder-directed HIV/AIDs programs for decades, it's also on the leading wave of increased infections among elders of all socioeconomic groups.
Open Communication
"There's a dangerous undercurrent at many medical visits that posing questions regarding intimacy, sexual history, or drug use to an elderly patient is a sign of disrespect," says Barreto. "This couldn't be further from the truth. A full, thorough medical history is the cornerstone of understanding and preventing a patient's medical concerns. Most importantly, do not bring any judgment. It can be difficult, but maintaining individual respect and compassion for each patient will solicit an open and communicative environment."
Elizabeth Nash, ACRN, MPA, regional manager of AIDS Healthcare Foundation/Positive Healthcare, Clearwater, Fla., advises nurses to be open and natural to normalize topics that often are taboo. "Ask open-ended rather than yes/no questions, such as 'Who are you having sex with?' rather than 'Do you have sex with your spouse,' and 'Tell me about your sexual activities, including vaginal, anal, and oral intimacy,'" she suggests.
Widows and divorcees often are excluded from educational efforts, says Nash, as are Hispanic women because of cultural emphasis on their monogamy. Healthcare providers and patients may miss diagnoses by blaming age-related conditions for symptoms such as weight loss, cognitive changes, and fatigue, that would raise flags in younger patients.
If birth control is unnecessary, elders may fear using condoms implies they or their partners are intimate with others, use drugs, or have infections, says Nash, who also is president of the Association of Nurses in AIDS Care's Tampa Bay chapter.
Condom PR
Elders may be embarrassed to buy or use condoms. "Because of impotency, older men can lose erections, so they may not want to stop to put them on," says Nash. "We distribute a lot that are labeled extra-large, to inflate their egos and encourage use."
Broward County's Seniors HIV Intervention Project, the country's first elder education program, provides peer "sexperts" including Miriam Schuler, the "Condom Grandma" who made national headlines in the 1980s.
"Speakers and outreach are very effective in changing behavior, and the impact of older people with real stories is very powerful when they're speaking to peers," says Marlene LaLota, MPH, prevention director at the state Bureau of HIV/AIDS. "We have [available speakers] like that all over the state, including black, Hispanic, gay, and ex-drug-users."
HIV/AIDS Epidemic in Elders
"We're seeing an aging of the epidemic, with a higher percentage of older folks … and I think we'll see that increase," says Spencer Lieb, MPH, senior epidemiologist for the Bureau of HIV/AIDS at Florida's Department of Health, Tallahassee. "More people with HIV/AIDS are living longer to transmit the infection, and we see more sexual activity because the population is healthier overall and using erectile dysfunction drugs. Most importantly, the person with HIV is converting to AIDS."
In 2007, 21,379 HIV/AIDS cases were diagnosed and reported in Floridians 50 and older, an incidence of 358.6 cases per 100,000 people. "It's under-diagnosed, so we're probably missing 10%," says Lieb. "And if they're reported in another state when they're diagnosed, they're not reported here." Since cases are reported wherever they're diagnosed, he says the number of seasonal residents reported in and out of state probably balance.
Every Florida county has reported cases of residents older than 50 living with HIV/AIDS, and counties with a population more than 100,000 have a minimum of 113 cases. The highest numbers are in Miami Dade (7,275 cases, 34% of the state's 50-plus cases); Broward (4,102, or 19%), and Palm Beach (2,337, or 11%), closely followed by Hillsborough, Orange and Duval, (3,923 cases combined, 18%).
Testing and Talking
Provider and patient stereotypes about both aging and HIV are contributing factors. Many people remain sexually active into their 80s and 90s, and with the use of erectile dysfunction drugs for the past decade, rates of HIV/AIDS and gonorrhea in heterosexual elders has increase faster than their counterparts who are younger than 40, says Lieb.
Professionals often are as uncomfortable thinking or talking about HIV and sex as older patients, says Elizabeth Nash, ACRN, MPA, regional manager of AIDS Healthcare Foundation/Positive Healthcare, Clearwater, Fla. "There's huge discomfort in taking a proper sexual history, and nurses and physicians don't even think about older patients' possibility of exposure. And AIDS has such a huge stigma in the medical community that some personal physicians ask if we're scared we'll get it from patient case management."
"If you're practicing in Florida anywhere, your patients are very high risk," says LaLota. In addition to a baseline test for all older adults, she advises retesting for those who are sexually active at least annually, and twice or more annually for men who have sex with men.
"Cost is not a barrier, and patients very rarely would have to pay for it," says LaLota. "If it's ordered, it's covered by insurance or Medicaid, and it's often included free, no appointment needed, on most mobile health units ... paired with other services and tests. "The health department's STD program visits patients who test positive, and identifies and contacts anyone who may have been infected."
Local health departments and HIV offices can offer providers and patients free resources, including condoms, speakers, assistance starting test sites or programs, and access to patient care services (including those who don't qualify for Medicare or Medicaid). Because of the stigma attached to STDs, testing and education are most effective when integrated or added to other health programs such as diabetes or exercise, says LaLota. Programs can be located by calling 211.
Original link available here: http://www.globalaging.org/health/us/2008/confronts.htm
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