The number of people over 50 living with HIV in the UK has sky-rocketed in the past decade from 3,644 in 2002 to 16,549 in 2011. More than 80% of British, Canadian and American adults between 50 and 90 are sexually active. With the risk of pregnancy sharply reduced in older women, the stakes of casual sex can appear lower despite an increased susceptibility of the immune system to infection.
"They just don't think it can happen to them", explains American clinical psychologist Judy Kuriansky. "[Sexually transmitted infections] really started making news in the '80s and '90s. The fears and the warnings didn't hit their generation." Is the rise in STIs among the over-fifties in the UK due to a generational gap, as Kuriansky suggests, or a shortcoming in health services?
It's arguably a bit of both. John O'Doherty, director of The Rainbow Project, a gay, lesbian and transgender rights organisation in Northern Ireland, believes that fear of stigmatisation has led to high numbers of undiagnosed HIV cases among older men. One in five new HIV cases in Northern Ireland are in men over the age of 45. O'Doherty frames the issue as both cultural and generational, especially when concerning older men who have sex with men. "We're dealing with a community which spent a large part of their adult years being a criminal based on their sexual orientation", he observes. "The new freedom and openness and visibility of our community has provided a lot more opportunities for relationships and to meet new people, so it does put them at increased risk".
The availability and quality of services can also impact the sexual health of the over-fifties. Left untreated, STIs such as genital herpes and syphilis can increase the risk of HIV transmission. Early diagnosis and antiretroviral therapy can dramatically improve and extend the lives of people with HIV. Older patients and doctors often mistake the symptoms of HIV for other conditions associated with ageing, such as weight loss and fatigue. 2011 data from the UK Health Protection Agency reveals that a higher proportion of adults over 50 (61%) are diagnosed later compared with younger adults (45%).
Doctors at the Royal Victoria Hospital in Belfast are addressing the problem among older men who have sex with men by running monthly outreach clinics in gay venues. "Some people find it a step too far to come to a [sexual health] clinic and some people really regard confidentiality as the holy grail", says Dr. Carol Emerson, a sexual health consultant at Royal Victoria. "[B]ringing the clinic out has increased testing, increased knowledge and increased diagnoses."
Confidential and convenient at-home testing could be instrumental in diagnosing HIV and STIs among the over-fifties, particularly older men who have sex with men. In December, the UK Department of Health announced plans to review its ban on HIV home testing kits. A 2011 survey by the UK charity Terrence Higgins Trust found that almost two-thirds of people would consider using HIV home testing kits if they were regulated and available. Of the 490 respondents that had not been diagnosed with HIV, 51% believed that home kits would motivate them to get screened more frequently.
The service delivery framework for home testing already exists within the NHS' National Chlamydia Screening Programme, which provides free testing kits via post to young adults under 25. Extending home-based STI screening programmes to the general population could help redress the gap in testing and treatment among the over-fifties and marginalised groups.
Along with screening, awareness and prevention strategies targeting the over-fifties should be scaled up. "Free condoms and sexual health leaflets would be a really helpful part of any service for older people", says Steve Myers, Director of Social Work at University of Salford. "Websites would also be helpful - there are an awful lot of silver surfers out there. It's empowering for people to access information themselves."
In 2010, the Family Planning Association launched The Middle-age Spread, a poster campaign featuring fashion clips from the 1970s alongside condoms. "Remember wearing this?" the ads ask, referring to the leisure suits and bell-bottoms. Below the text is an image of a condom: "Then remember to wear this!"
A recent survey by Age UK points to the importance of outreach through informational sessions in clinics and care homes. The charity's online poll of over 2,000 people found that 69% of respondents over 65 had never sought sexual health advice. Health providers and social workers should take the first step in ensuring informed sexual decision making among the elderly. "Social workers need to talk to everyone about these issues - it's about acknowledging that it's an important part of people's self-image and well-being", argues Myers.
"People don't like to think about older people being sexual beings but it's self-fulfilling - if we don't talk about it then it will remain hidden."