Questions & Answers: Prevention of sexually transmitted and blood borne infections among older adults

What do we know about sexually transmitted and blood borne infections (STBBIs) among older adults in Canada?

In 2011, adults over 50 years old comprised more than 35% of Canada's population, an increase of over 15% from 2006^Footnote6. As Canada's population continues to grow older, live longer, and enjoy better health, there has also been a rise in STBBI rates in this demographic.

Although younger people continue to account for the highest rates of STBBIs, epidemiological data indicate that rates among older adults are increasing^Footnoteii. For example, in 2011, adults aged 50 and older represented 18.2% of all positive HIV tests in Canada, up from 10.6% in 1999^Footnote7. The number of those over 50 who are living with HIV also continues to rise as advances in HIV care increase the number of people living with HIV (PHA) who survive into older age. While overall prevalence of most STBBIs among this population remains significantly lower than younger age groups, recent trends do indicate that prevalence is increasing. Between 2002 and 2011, chlamydia cases in people over age 60 have increased over three times (from 93 in 2002 to 309 in 2011), gonorrhea cases have more than doubled (from 64 in 2002 to 154 in 2011), and syphilis cases have increased close to five times (from 13 in 2002 to 69 in 2011)^Footnote8. During the same time period, women over age 60 had the highest relative rate increase (over 269%) for both chlamydia and gonorrhea^Footnote9. Similarly, recent data indicate that the prevalence of hepatitis C for those aged 50 to 79 is twice as high as those aged 14 to 49, representing almost two-thirds of all chronic infections^Footnote10.

What are the individual and behavioural factors that impact sexually transmitted and blood borne infection (STBBI) prevention for older adults?

Knowledge and awareness

Studies have demonstrated that adults over 50 are less knowledgeable about STBBIs, their transmission routes, and prevention techniques^Footnote11. Low levels of knowledge and awareness can be attributed to several factors. First, there is a lack of information about STBBIs tailored to this population. Second, STBBI prevention messaging is predominantly geared toward a younger audience, often as a result of the perception that those over 50 are not at risk for STBBIs^Footnote12. Third, school based sexual health education, for those who may have received it, focused more on sexual morality than sexual physiology and would not have covered topics such as HIV and hepatitis C as they had yet to become a concern^Footnote13. Lastly, this age group has often been excluded as an area of focus for research addressing sexual activity, sexual behaviour, and STBBI risk. This has limited the ability to create evidence-based educational prevention messaging that is adequately tailored to this population^Footnote14.

Attitudes

In general, older adults do not perceive themselves to be at risk for STBBIs^Footnote51. The lack of targeted STBBI education, information, and programming available may suggest that they are not susceptible to STBBIs, reinforcing the misconception that this age group is not at risk^Footnote16. This low perception of risk can limit the adoption of STBBI prevention behaviours and may contribute to lower rates of testing^Footnote17. Attitudes toward dating may also contribute to increased risk for STBBIs for those within this population who seek less serious or casual relationships^Footnote18.

It is estimated that 44% of people infected with hepatitis C are unaware of their infection^Footnote19. As indicated earlier, some may have been exposed to the virus many years ago as a result of sharing drug equipment (even once) or through medical procedures or blood products. Since many do not presently engage in risk behaviours for hepatitis C, such as injection drug use, they may have a low perception of risk.

Risk behaviours

Research indicates that older adults share the same risk behaviours for STBBIs as younger adults, including unprotected sex, multiple sexual partners, and low rates of STBBI testing^Footnote21. Low levels of condom use and STBBI testing observed in this population have been attributed to a low perception of risk for STBBIs^Footnote22. Decreased condom use may also be attributed to the perceptions around decreased risk of pregnancy for those over 50^Footnote23. Interventions that address sexual risk behaviours among older PHA have been shown to be effective, especially those that provided essential information on STBBI risk, condom use and negotiation skills^Footnote24.

Programs and interventions that address the low levels of knowledge, awareness and perceived risk amongst this population would be an integral component of STBBI prevention and can provide those over 50 with valuable information and skills to address potential risk behaviours and protect themselves from STBBIs.

What are the interpersonal, social, and community network factors that impact sexually transmitted and blood borne infection (STBBI) prevention for older adults?

Relationship status

As adults progress through the various lifecourse stages, some may face a change in their relationship status due to the loss of a partner through widowhood, separation, or divorce^Footnote25. Additionally, some may choose this time in their life to openly express a sexual orientation or gender identity that was suppressed in their younger years. These life events can create a situation where older adults are re-entering a dating scene which may be quite different from the one they remember.

Relationship environment

The social environment within which those over 50 are forming new sexual relationships has also changed since they were younger. For example, technology has resulted in the growth of the online dating industry which older adults have been accessing to make social connections. Research suggests that online dating may lead to increased sexual risk^Footnote26. Sexual activity in older age has also seen an increase resulting from the marketing and use of erectile dysfunction medication which serves to facilitate a more active sex life among those over 50^Footnote27.

Engaging in safer sexual relationships requires honest and open communication between potential partners. Some adults over 50 report difficulty in communicating with their new partners when it comes to discussing sexual history, drug use behaviours, and negotiating safer sex^Footnote28. Conversations about such topics can be daunting and many may feel unequipped with the necessary knowledge or communication skills to discuss them comfortably.

Health care providers

Sexual health concerns, including STBBIs and drug use behaviours, are not subjects that are routinely discussed by older adults and their health care providers^Footnote29. Health care providers often overlook this population as an audience for sexual health and STBBI education and prevention, and are reluctant to initiate the conversation with these patients^Footnote30. The assumption that these clients are not engaging in high-risk behaviours also limits the willingness of health care providers to test and screen for STBBIs. At the same time, those over 50, and in particular women, are less likely to raise questions or to bring up the topic unprompted^Footnote31. Yet studies have shown that the majority within this population indicate they would like to receive more sexual health information from their health care provider^Footnote32. Those who do receive STBBI information from their health care provider have been found to have higher STBBI knowledge and awareness than those who receive their information from other sources^Footnote33.

Travel and Snowbirds

Retirement provides an increased opportunity for travel for many Canadians. Travelling, either in a group or independently, provides the opportunity to meet new people and expand social networks while also increasing the potential of new sexual partnerships. International travel has also been associated with increased sexual risk-taking^Footnote34.

Florida, home to more than a half million Canadian snowbirds every year, has the highest HIV and sexual risk behaviour rates for those over 50 in the United States^Footnote35. One study of Canadian snowbirds demonstrated that they were engaging in sexual risk behaviours, such as inconsistent condom use and multiple sexual partners, and had low participation rates in HIV testing^Footnote36.

Addressing the issues and concerns which may be raised as a result of changes to one's relationships and social environments can help to empower adults over 50 to limit their risk to STBBIs. Enhancing their communication with service providers and partners through education and skills training may also increase their ability to engage in safer sexual behaviours.

What are the social, structural, and economic determinants that impact sexually transmitted and blood borne infection (STBBI) prevention among older adults?

There are several health determinants which can impact STBBI prevention among older adults including:

• discrimination and ageism;
• mental health and mental illness;
• social connectedness;
• socio-economic status;
• gender;
• sexual orientation.

The impact of these determinants on an older adult's vulnerability to or resilience against STBBIs can vary greatly depending on their life histories to this point and their present lifecourse stage. For example, the effect of socio-economic status could be quite different for a 55 year old who is currently employed as compared to a 75 year old widower on a fixed income. Additionally, the effect of these determinants can continue to evolve and change as people continue to age and transition through further life stages. It is important that health care and service providers be aware of how these determinants may affect their clientele based on individual circumstances and life stages in order to ensure the greatest impact of STBBI prevention programs and interventions.

While most of the current literature focuses on the impacts of these determinants on the vulnerability of older adults to STBBIs, lessons can be learned from research conducted on fostering resilience among other populations. Evidence in this area demonstrates that factors such as strong social support networks and supportive communities and social environments can have a positive impact on a person's resilience against STBBIs.

Discrimination and Ageism

Ageism is discrimination based on a person's age and is expressed by how we think about older adults, both in our social and historical perceptions of aging, and how we tend to structure our society to address the needs of younger adults and thereby neglect the needs of older ones^Footnote37. Ageism, which can be overt or systemic, takes many forms, including inequitable treatment and access to resources, and abuse of various kinds including psychological, physical and financial.

Experiences of ageism may differ as a result of the multiple characteristics and varied life experiences that make up a person's identity. Ageism can be experienced alongside other forms of discrimination based on race, ethnicity, disability, gender identity, or sexual orientation. For example, those who are also members of lesbian, gay, bisexual and transgender (LGBT) communities may experience multiple layers of discrimination in the form of homophobia, heterosexism, and ageism. Similarly, for older adults who are living with a chronic STBBI such as HIV, the resulting stigma and discrimination can affect their access to health and social services and to information and educational resources^Footnote38.

Experiencing ageism can have a negative effect on identity, sexuality, and mental health, including self-esteem and self-efficacy. Internalized ageism, or the extent to which older adults absorb the social norms that devalue them, may have negative effects on their physical and mental health^Footnote39. Accompanying ageism is the fear of potential rejection from service providers, family, and friends as a result of misconceptions related to age. Ageism can affect one's ability to access sexual health education, services, and programming as well as the development of tailored STBBI messaging^Footnote40.

The stigma and discrimination that this population may experience can affect STBBI prevention, treatment, care, and support, and can contribute to poor health outcomes. Individuals and communities alike can help combat ageism and discrimination by reflecting upon their own perceptions and attitudes towards this population group. As well, talking with older adults about sexuality, learning about aging and the issues they face may help service providers to better appreciate the needs and realities of those over 50.

Mental health and mental illness

The prevalence of mental illness among older adults in Canada remains high. This includes those growing older with a mental illness and those who are experiencing the onset of mental illness in their older years^Footnote41.

There is a strong relationship between poor mental health, mental illness, and vulnerability to STBBIs^Footnote42. Depression, low self-esteem, and low self-efficacy have been shown to affect the development and maintenance of safer sex practices in older PHA^Footnote43. Individuals with higher levels of self-efficacy reported intention to engage in safer sex, as well as decreased rates of HIV risk behaviours^Footnote44.

Those over 50 can also experience poor mental health as a result of changing social roles, relationships and life transitions including retirement, bereavement, caregiving and a loss of independence over their personal environments. The change in daily routine and the elimination of work-related stressors that accompany retirement can have an immediate positive effect on mental health and functioning. However, the potential loss of social interactions and accustomed routines, increased isolation, and concerns about financial security may contribute to an increased risk of depression over the long term^Footnote45.

The profound feelings associated with bereavement can trigger emotions that take time to process. Depression is the most common mental illness that can result from bereavement. While most individuals will eventually work through the varying stages of bereavement, some may not, and the associated depression can deepen over time. Additionally, older PHA may experience a prolonged sense of bereavement due to the loss of many of their peers^Footnote46.

Positive mental health, including self-esteem, self-efficacy, a sense of worth, satisfaction with life, and a resilient mindset have been shown to support the overall health of older adults and are protective factors from acquiring mental illness^Footnote47.

It is important to remember that poor mental health is not a natural part of aging. The assumption that it is can discourage individuals from seeking treatment or mental health support services. Through interventions and community action, service and health care providers can address the risks faced by this population and improve their positive mental health. Programs which promote positive mental health have been found to reduce the risks of mental illness and may thereby decrease one's vulnerability to STBBIs.

Social connectedness

As adults move through their lifecourse they may experience changes to their social networks and support systems. Life experiences and a person's ability to adapt can influence their response to these changes. Some individuals may actively seek out new social contacts while others may withdraw from social connections and activities, which can lead to isolation. Both responses can affect vulnerability to STBBIs.

Interactions with spouses, partners, friends, and colleagues provide both social support and guidance and are important in maintaining one's physical and mental health. The gradual loss of these networks and relationships as people age can result in a degree of social isolation which many may counteract by seeking comfort and support in new relationships. New living environments can also provide the opportunity to form new relationships. Adult living communities, retirement homes, and assisted living facilities can all serve to introduce individuals to potential new partners and may increase sexual contacts and risk behaviours^Footnote48.

For others, diminishing social networks may result in decreasing levels of social participation. Those who take on the role of caregiver for a parent, partner, or loved one are at an increased risk for social isolation due to their limited time and capacity for social interactions. Over time, social isolation has been attributed to lower levels of physical and mental health which may impact one's vulnerability to STBBIs^Footnote49.

Socioeconomic status

While older adults in Canada enjoy an improved standard of living compared to generations past, they are still disproportionately represented in the lower socioeconomic categories in Canada.

Multiple factors can contribute to lower socioeconomic status among older adults, and in particular those over the age of 65. These include retirement and diminished opportunities for employment or advancement, limited or fixed incomes, changes to pension funds, the death of a spouse, and ageism^Footnote50. For those adults over 50 and living with a chronic STBBI, the increased economic costs of self-funded services (e.g. rehabilitation services and complementary and alternative therapies) and the physical and structural limitations which may have impaired their ability to work and earn income when younger, can further impact their present socioeconomic status^Footnote51.

Research indicates that many older adults with lower socioeconomic status have increased rates of chronic disease and lower health-related quality of life scores. They report receiving less medical treatment and having poorer access to health services than their higher-income peers^Footnote52. Furthermore, those living on low incomes are more likely to suffer from health conditions related to poor nutrition and in recent years have increased their use of food banks^Footnote53. All of these factors can have an impact on health outcomes and vulnerability to STBBIs^Footnote54.

Gender

Many women over 50 report greater difficulty talking about safer sex and sexual health concerns with both their health care providers and potential sexual partners^Footnote55. Even when aware of the sexual health risks, they are more reluctant to raise the issue of condom use with their sexual partners for fear it will result in conflict or rejection. In older age groups, the greater proportion of women to men can also affect the power of older women to negotiate safer sex with male partners. The women may consent to the man's preference to not use condoms out of fear that he may leave for another available partner^Footnote56. Taking these factors into consideration is key to improving the health communication skills and self-efficacy of women over 50 in order to empower them to take control of their sexual health.

Sexual orientation

Older gay, bisexual, and other men who have sex with men (MSM) also face increased vulnerability to STBBIs when compared to other older adults. Messaging, programs, and interventions addressing STBBIs among this population are primarily targeted at the younger generation. This neglects the education and prevention needs of older gay men and other MSM^Footnote57. Interviews with those who have lived through the HIV epidemic of the 1980s and have had long-term exposure to safer sex campaigns indicate that they are experiencing 'condom fatigue'. This may result in an increase in sexual risk behaviours^Footnote58. This population also reported being less likely than their heterosexual peers to seek health care and social services out of fear of discrimination^Footnote59. Older lesbian and bisexual women report similar experiences and are less likely to share information about their sexual health and intimate relationships with their health care providers as a result of prior negative experiences in disclosing their sexual orientation^Footnote60.

One recent study that examined the physical and mental health of transgendered older adults found that this community was at a significantly higher risk for poorer health, depression, stress and disability in comparison to their non-transgendered LGBT peers^Footnote61. Additionally, gender identity was found to indirectly impact health through a fear of accessing health services, lack of social support, victimization and stigma, all of which can increase vulnerability to STBBIs.

Adults who are coming out at an older age may also face increased vulnerability as a result of their newly expressed sexual orientation. Lack of familiarity with same-sex relationships, including safer sex negotiation, uncertainty about where to access services and which ones are most appropriate to them, and the fear of stigma and rejection from family and friends can all affect their ability to protect themselves from STBBIs^Footnote62.

What are the key considerations for sexually transmitted and blood borne infection (STBBI) prevention among older adults?

Co-morbidities

The incidence of chronic conditions including high blood pressure, arthritis, heart disease, diabetes, and cancer increases with age. Chronic conditions and their subsequent treatments can weaken or suppress the body's natural immune response thereby increasing the risk of STBBIs^Footnote63. Those living with one or more co-morbidities report taking three or four prescription medications daily, a number that increases with the number of co-morbidities^Footnote64. The additional medication required to treat an STBBI, when combined with their existing treatments and the decline in liver and kidney function associated with advancing age, can increase the risk of adverse drug reactions and potential side effects^Footnote65.

The management of co-morbidities can be complex. Each chronic condition may require different health care providers and methods of treatment and care, which can be difficult to coordinate and manage. Older adults report multiple barriers to navigating the health care system, including physical barriers such as limited mobility and access to transportation. These barriers may further increase their vulnerability to STBBIs by affecting their ability to attend medical appointments and prevention programs, or to obtain medications^Footnote66.

The experience of co-morbidities can affect STBBI treatment decisions, issues of treatment adherence, and the complexity of disease management. Health care providers need to be aware of these issues and be prepared to treat and offer rehabilitation services to address multiple co-morbidities.

Challenges in diagnosis

Many of the signs and symptoms associated with some STBBIs, such as fatigue, weight loss, and loss of appetite, mimic the signs of normal aging and can complicate making an accurate and timely diagnosis and developing a subsequent course of care. The relatively asymptomatic nature of some STBBIs further complicates the diagnosis because many older adults are not as likely to seek treatment or testing for an STBBI unless symptoms have occurred, and even then they are less likely to seek testing^Footnote67. The lack of STBBI risk perception can also result in the dismissal of symptoms when they do arise. Many health care providers, especially those who do not understand the intersection of STBBIs and aging, are also likely to dismiss STBBI symptoms as being age-related^Footnote68. These delays to diagnosis, and ultimately treatment and care, can result in some older adults presenting at more advanced stages of infection, leading to a higher likelihood of complications and poorer prognosis^Footnote69. This underlines the importance of education for this population and their health care providers, and screening for those who are at risk even if symptoms of an STBBI are absent.

Biological and physiological changes

The loss of immune system function is a natural occurrence of aging. It is associated with an increased susceptibility to infection and can affect an individual's response to treatment. The decreased function of the immune system in older adults has been suggested as one of the reasons they are more likely to progress rapidly from HIV infection to AIDS^Footnote70. Fewer properly working immune cells also increase the time needed to heal from infections, thereby increasing the length of time where one is at increased susceptibility for STBBI co-infection^Footnote71.

Age-related changes in biological function can also increase the risk of STBBI among older women. Lowered estrogen levels, which begin in the early stages of menopause, can lead to decreased vaginal secretions during sex and a thinning of the vaginal walls. This can result in an increase in tissue damage during sexual activity which can facilitate the transmission of STBBIs^Footnote72. Similarly, those who engage in anal sex are also at increased risk due to the increased frailty of the anal tissue which becomes more prone to tearing. It is important that education and prevention programs provide this population with the knowledge and tools required to address their biological risk. Practical suggestions and strategies to maintain intimacy while decreasing risk and ensuring access to condoms and other prevention services can help empower older adults to take control of their sexual health.

Cognitive impairments

The gradual decline in various aspects of cognitive functioning is a natural part of aging and generally begins before age 50. This includes declines in:

• memory;
• executive function (planning, strategizing, and self-regulation);
• processing speed;
• reasoning.

Over time, normal cognitive decline can have some effect on one's functional abilities, including the ability to learn, make decisions, and follow medication regimes, which can increase vulnerability to STBBIs^Footnote73. The decline in executive function can also affect communication skills, which can further impair a person's ability to negotiate safer sex.

Cognitive impairments can also inhibit rational decision-making, affect the ability to adequately assess personal risk, and impair impulse control, which can play a role in increasing risk behaviours^Footnote74. Additionally, those living with other chronic health conditions such as cardiovascular and neurological diseases are at increased risk for cognitive impairments. The neurological consequences of these conditions or side effects from medications can often impair cognitive functions and communication skills beyond what is expected with aging.

Cognitive impairments affect the health of older adults in many ways. Community organizations and service providers can help mitigate these effects by addressing the impact of cognitive impairment directly through their work. Interventions and programs that understand and address the cognitive impairments associated with aging are essential to the prevention of STBBIs among this population.

What are the key considerations for older adults living with chronic sexually transmitted and blood borne infections (STBBIs), HIV, and hepatitis C?

While living with a chronic STBBI, such as HIV, can have a restrictive effect on sexual relationships due to concerns about prevention of onward transmission and disclosure, many older PHA continue to be sexually active^Footnote75.

As HIV can increase the risk of acquiring other STBBIs, it is important for older PHA to continue to protect themselves from other infections. Older adults living with chronic STBBIs also play a significant role in reducing risk for others. Research indicates that older PHA do engage in sexual risk reduction strategies to protect themselves and their partners, and interventions aimed at increasing risk reduction behaviours among this group can be effective^Footnote76. The meaningful engagement of this population, through their inclusion in the development and implementation of STBBI policies and programs, is seen as an important aspect of STBBI prevention efforts^Footnote77.

Separate from the issues associated with aging, the health outcomes of older adults living with chronic STBBIs can be further impacted by the following:

• disclosure;
• access to treatment, care and support;
• increased risk for other health conditions;
• psychological and physical well being.

It is important for these issues to be taken into consideration when planning STBBI prevention programs for this population.

Disclosure

Disclosure of one's HIV or hepatitis C status to others, such as family, friends, health care and other service providers is a highly personal decision. People living with chronic STBBIs can make very different decisions about whom to tell and when. While the issue of disclosure can be of concern for those living with chronic hepatitis C, little research investigates the topic. For older PHA, the decision to disclose involves weighing many of the same consequences and benefits to disclosure as younger adults. However, research indicates that, overall, older PHA are less likely than their younger peers to disclose their status to friends, sexual partners, and health care providers^Footnote78. It is estimated that close to 50% have not disclosed their status to their friends, thereby decreasing their opportunities for social support and the chance to discuss and implement treatment options and HIV risk reduction strategies^Footnote79. Higher rates of disclosure are associated with a longer length of time since diagnosis, accessing HIV-related services and the availability of social support^Footnote80.

Concerns related to stigma, discrimination, and rejection by family and friends are factors that can affect their decision to disclose their status^Footnote81. However, some feel a responsibility to provide guidance to younger generations and view disclosure as an opportunity to educate others, making them a key partner in STBBI prevention^Footnote82.

Access to treatment, care and support

The increasing number of older adults living with chronic STBBIs, either long-standing or newly diagnosed, poses challenges for various aspects of the health care delivery system and the ability of this population to adequately access it. Traditionally, HIV or hepatitis C care has been provided by infectious disease specialists. As those living with chronic STBBIs grow older, many of these health care providers are not equipped to handle the diverse health care needs associated with aging^Footnote83. Furthermore, those adults over 50 who are newly diagnosed with a chronic STBBI may find their family practitioner or gerontologist unfamiliar with addressing the needs associated with their new diagnosis. As a result, this population often requires two sets of medical providers, which can be a barrier to accessing treatment, care, and support due to costs, transportation concerns and an increased number of appointments.

Older PHA can further experience a 'double jeopardy' where they experience ageism in accessing AIDS service organizations (ASOs), and HIV stigma in accessing non-HIV services^Footnote84. HIV service organizations may not yet be adequately prepared for older clients and integrating them into programs and services designed for younger people may limit their effectiveness in meeting the needs of both older and younger adults^Footnote85. Additionally, those who are newly diagnosed may have limited knowledge of what HIV-related services are available to them and where they can be found, since many of these service organizations do not target older adults in their awareness campaigns and educational materials.

Given the growing number of adults over 50 living with chronic STBBIs, it is important that community organizations, service providers, and health care professionals work collaboratively to meet the treatment, care, and support needs of people who are both aging and living with a chronic STBBI.

Increased risk for other health conditions

Advances in treatment are allowing people living with chronic STBBIs to live longer. PHA are now expected to have a relatively normal lifespan. Similar to other adults, they are at risk for chronic conditions associated with aging, including cardiovascular disease, diabetes, arthritis, dementia, and some cancers. However, older adults living with chronic STBBIs have a greater susceptibility to these chronic conditions than the general population^Footnote86. This increased susceptibility may be caused by the infection, the side effects of antiretroviral medication, or a combination of the two. For those who are co-infected with HIV and hepatitis C virus (HCV), the risk of co-morbidities, including liver disease, is even greater than those who are only HIV positive^Footnote87. The existence of co-morbid conditions can also make HIV and HCV more complicated to manage and may limit treatment options. Whether PHA develop these conditions at a younger age then those who are HIV negative is an area presently being investigated^Footnote88.

It is important that community organizations and service providers take into consideration the range of health issues faced by this population, which can limit their participation in STBBI prevention. Addressing quality-of-life concerns, while providing for flexibility and adaptability of programs to meet their needs, can help ensure potential barriers are removed.

Psychological and physical wellbeing

For adults living with a chronic STBBI, aging can prove to be challenging both physically and psychologically. The response of older PHA to anti-retroviral therapy is sometimes more complex than younger PHA due to a lower CD-4 cell recovery in response to treatment and the management of other age-related conditions^Footnote89. These complications can result in frequent adjustments to medications which can increase the likelihood of undesirable side effects. These side effects include fatigue and diarrhea and can contribute to social isolation and decreased treatment compliance^Footnote90.

Studies have shown that older PHA are significantly more socially isolated than younger PHA, a trend that continues to increase with age^Footnote91. Stigma, discrimination, and the loss of friends and social networks have been cited as potential reasons for the social isolation that they experience^Footnote92. Older PHA also experience elevated levels of depression when compared to the general population, which has been linked to decreased treatment compliance^Footnote93. Furthermore, uncertainty about the future and the unpredictability of aging with HIV are common concerns and a cause of anxiety^Footnote94.

People living with a chronic STBBI include those infected in older age and those growing older with the infection. The length of time that they have been living with a chronic STBBI has important implications for their experiences and can affect their needs with respect to education and services, their attitudes and levels of comfort with the diagnosis, sharing of information, and the various issues surrounding living with a chronic STBBI. Health professionals and educators can work with this population to help define the issues that most affect them and learn about their diverse needs in order to meet the goal of aging well with a chronic STBBI.

What can I do to support sexually transmitted and blood borne infections (STBBI) prevention among older adults?

Personal

• Reflect on your own, and your organizations', values and beliefs about sexuality, older adults, and aging. What assumptions are you bringing to your work with older adults? Taking an inventory of your values, attitudes, assumptions, and beliefs can highlight biases and help you to recognize how your own values might influence how you provide STBBI prevention programs for this population.

Programming

• Adopt a life course approach to healthy aging that recognizes the influence of life events and transitions on the abilities of older adults to act on health information and make healthy decisions. For example, integrate sexual health and STBBI prevention information into retirement planning sessions offered through local community centres.
• Engage older adults, especially those who are living with HIV and hepatitis C, in the development and delivery of programs. Older adults can act as information resources and peer educators in the community. Learning from members of their own community who share similar experiences can:
  • improve older adults' understanding, acceptance and the ability to apply STBBI prevention principles;
  • increase the likelihood that STBBI prevention strategies are incorporated into personal health practices;
  • build resiliency and capacity among community members.
• Encourage older adults to get involved in volunteering with health promotion and education programs. Volunteering can help to maintain a sense of purpose and belonging and serves to maintain self-esteem, life satisfaction, and social support.
• Develop age-appropriate and culturally appropriate messages for use in educational materials and programming. Messaging that reflects the needs of older adults and the desired outcomes and behaviours can:
  • increase awareness of personal risk;
  • provide appropriate factual information;
  • specifically link risk reduction with the experiences and situations facing older adults.
• It is important to tailor content to different living arrangements and contexts such as community, retirement homes or care facilities. Try to ensure that information materials are accessible for those with visual or hearing impairments.
• Develop STBBI prevention resources that can be accessed independently. Some older adults, such as those living in rural and remote areas or those who are facing mobility challenges, may not be able to access programs and resources that require in-person attendance or that are set up in gathering places. Consider developing resources and programs that can be offered over the internet, by telephone, or ordered by mail. For example, set up training sessions for staff to learn motivational interviewing skills and provide STBBI information by telephone to older adults aimed at reducing sexual risk behaviours. Also, consider linking program websites to existing organizations or agencies that address STBBIs among older adults to help people navigate the system more easily.
• Offer skills-building workshops to enhance older adults' comfort and ability to communicate sexual health needs, disclose STBBI status, and negotiate condom use. Increased confidence and competency can enhance their ability to implement safer sex practices with their sexual partners. Skills-building sessions also provide the opportunity to increase social support and social interaction opportunities for older adults.
• Establish support groups for older adults that provide an opportunity to connect with their peers to discuss and share experiences of aging and its impact on psychological, spiritual and physical well-being.
• Provide assistance to older adults in managing their infections. For example, a reminder system could be created wherein health care providers or peers place telephone calls or send text messages to help older adults adhere to their treatment schedule.
• Encourage older adults to practice safer sex by ensuring that resources are readily available to them. For example place condoms in accessible areas such as doctors' offices and long-term care facilities.

Note: At present there is very little research or published evaluations regarding effective STBBI programing and interventions targeting older adults. Further evidence is required to help guide the programmatic response to addressing STBBIs among this age group^Footnote95.

Capacity building

1. Build on the available information concerning STBBI prevention and older adults. Research, surveillance, and program evaluations specific to their context can inform interventions, programs, and activities. Areas could include:

• the impact of determinants of health on aging with or without STBBIs;
• barriers to STBBI care for older adults;
• improved monitoring of risk behaviours in older adults.

Results from research and program evaluations could be shared with:

• other community organizations;
• local health authorities;
• care providers for older adults;
• provincial or territorial ministries of health;
• other policy-makers.

For example, present the findings from the evaluation of your activities at local health conferences, symposia, or summits. Sharing evidence about programs and interventions that show promise in preventing STBBIs and improving health outcomes can help others develop programs, policies, or interventions in their own jurisdictions.

2. Set up continuous learning opportunities for staff and service providers to learn about:

• how the aging process affects STBBI vulnerability;
• the ways in which social, cultural, and economic conditions affect sexual behaviours, access to programs or services, and vulnerability to STBBIs;
• strategies for communicating sexual health and STBBI information with older adults;
• the unique needs of older adults living with chronic STBBIs like HIV and hepatitis C.

For example, create a continuing education module that addresses STBBIs among older adults and provides communication strategies on how to start the conversation. This module could be provided to practicing health care professionals through their professional organizations and to students as part of their curriculum.

Partnerships and collaboration

1. Work with seniors' organizations, residential facilities and other community organizations that provide care and support to older adults to address common health concerns among this population. Hold regular forums with these community partners to exchange ideas and identify areas for collaboration while working toward common goals. For example, collaboration between seniors' organizations and STI clinics can increase the capacity of service providers to make referrals for services and resources outside of their own sectors.
2. Improve coordination between service providers by offering STBBI testing and related services at a central access point where patients can access both medical and social services. For example, offer STBBI testing along with screenings and wellness exams, flu shots, mental health screenings, blood pressure check-ups, or a social event.
3. Collaborate with other community groups and services organizations to address ageism and its effects on health. For example, create or build onto an existing public awareness campaign to combat ageism. Providing a realistic portrayal of older adults as active and contributing members of society can both counteract the myths and stereotypes associated with aging and empower older adults to recognize the ageism they experience and respond to it.
4. Provide services in a variety of settings. Multiple points of access within the community will greatly enhance the ability of older adults to access STBBI prevention information and programs. For example, consider establishing mobile services to offer STBBI testing and medication drop-offs where they live, such as retirement complexes or assisted living facilities. Additionally, sexual health information could be built into programming in seniors' centres and recreation centres to ensure access to the information.
5. Create tools to increase awareness of STBBI programs and services available in the area. Older adults may be less likely to access services because they are unaware of what is available to them. For example, collaboration could be considered with other community organizations to establish a resource database of programs and services related to STBBIs for older adults. The database could be shared with the community in a variety of formats including public websites or in print form in a variety of settings such as retirement homes and assisted living communities.
6. Consider partnering with tour companies and travel agencies that provide services for older adults to offer STBBI prevention, information and toolkits, including condoms, to snowbirds and frequent travellers.

How can I help to build resilience among older adults?

Resilience requires a set of skills or a way of thinking that enables individuals to cope with stress and adversity. Building resilience is important throughout life to enable individuals to overcome challenges and avoid the effects of risks they face, especially as they move into older age. Poor coping skills, combined with social, structural, or economic barriers can limit opportunities available to older adults and affect their ability to cope with negative experiences and circumstances that impact their health.

Research has shown that several resilience factors are associated with positive aging^Footnote96:

• access to supportive relationships (peers, family, community);
• a strong personal identity (sense of purpose, beliefs, and values);
• a strong sense of personal power (ability to effect change in your own environment);
• a positive outlook on aging (remaining hopeful about an uncertain future);
• an ability to accept help and support (ability to re-value dependence as a way to adapt to changing circumstances);
• an ability to change and adapt (be open to new ideas, values, and experiences);
• a balanced view of life as a result of wisdom and insight (capability to analyze and understand situations);
• the power of giving (finding ways to be meaningful to others).

Community organizations, health professionals, and service providers can do several key things to build the resilience of older adults.

• Facilitate opportunities for older adults to remain socially connected, including activities and programs that strengthen existing social ties and enable the creation of new ones. This can lead to decreased isolation and improved health as well as a stronger sense of belonging for both individuals and their communities.
• Build individual capacity by creating opportunities for older adults to maintain a sense of purpose in their lives. Engaging in activities and functions, such as volunteering, can allow for continued personal growth and a chance to participate in meaningful roles by helping one another. This can lead to an increased sense of self-worth and self-esteem and provide a more positive outlook on themselves and their community.
• Help create and promote environments that are safe and inclusive to older adults. Accessible environments that are tailored one's specific needs and abilities can increase their level of community integration and provide greater opportunities for social interactions.
• Increasing understanding and awareness among individuals and communities of the impact of ageism and other forms of discrimination can help dispel stereotypes while improving the sense of belonging and identification among older adults.
• Support older adults in maintaining a healthy diet and active lifestyle and addressing modifiable risk factors such as smoking and substance use. Staying physically and mentally active and healthy can reduce stress and depression and improve quality of life.

Although older adults can experience stressful life events and negative circumstances that place them at risk for STBBIs, many have sources of strength that help them cope and adapt positively. Older adults with strong social support networks and positive beliefs about themselves and their life situations are more capable of making positive health-related decisions and avoiding negative health outcomes, such as STBBIs. Community organizations, health professionals, and service providers have an important role to play in helping to protect and improve the health of this population by fostering resilience and building individual and community capacity.

Concluding remarks

It is important to recognize that disparities that affect vulnerability to STBBIs continue to exist into older age. Multiple factors across the lifespan contribute to vulnerability to STBBIs. As a result, some older adults are diagnosed with STBBIs later in life while others are aging with chronic STBBIs resulting from exposure at a younger age.

Given Canada's aging population, integrated STBBI prevention strategies should consider all aspects of an individual's health and recognize sexual health and STBBI prevention as important components of healthy aging. It is also important for STBBI programs, policies, and interventions to address the various social, structural, and economic determinants of health that affect vulnerability to, and resilience against, poor health outcomes among adults over 50.

Older adults in Canada are a diverse demographic with varying needs and life experiences.Addressing STBBIs among this population requires an individually tailored and multifaceted approach. Providing age-appropriate and culturally appropriate education materials, supporting inclusion and engagement in the community, enhancing self-efficacy and capacity to communicate sexual health needs, and addressing societal attitudes, misconceptions, and age-related discrimination related to STBBIs can provide opportunities for adults over 50 to make healthy choices and maintain quality of life. Adopting a broader perspective of aging in addressing STBBIs—one that focuses on wellness and individual strengths—can help reduce health disparities and improve health outcomes for all older adults.