Objective: An unusual increase in HIV/AIDS cases among rural older adults was reported between 2005 and 2008 in Xiangxi Prefecture, Hunan Province. We explored the reasons for this increase and suggested preventive measures for the future control of HIV infection in this population.
Methods: A cross-sectional study was conducted using an HIV/AIDS registry in Hunan Province, China, to explore the likely transmission mode and risk factors of HIV/AIDS among older adults. The data were collected by face-to-face interview.
Results: A total of 80 participants including 5 couples were interviewed. Among them, 46 (57.5%) participants were male and 34 (42.5%) were female. Of 46 male HIV-positive participants, 45 (97.8%) reported to have sexual intercourse with commercial sex workers. None of the female HIV-positive participants reported to have engaged in commercial sex activities. Among 46 male participants' spouses, 71.7% of them had received HIV testing and 48.5% were HIV-positive. Among 34 female participants' spouses, 92.2% of them had received HIV testing and 87.1% were HIV-positive. Ninety-seven percent of the participants reported never using condoms during sexual intercourse with their marital partners or commercial sex workers before knowing their HIV status. Eighty-two percent of participants did not know that condoms could prevent HIV/AIDS/STIs.
Conclusion: Chinese older adults are an underappreciated at-risk population for HIV/AIDS. The likely transmission mode of HIV/AIDS among rural older adults was unprotected sex. The HIV/AIDS/STIs knowledge among this population is very limited.
From the *Department of AIDS/STD Control and Prevention, Hunan Provincial Center for Disease Prevention and Control, Changsha, People's Republic of China; †School of Public Health, Central South University, Changsha, People's Republic of China; ‡National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, People's Republic of China; and §School of Public Health, Yale University, New Haven, CT
X.C. and X.L. contributed equally to this work.
Supported by the China National Mega-project of science Research No. 2008ZX10001–003 and the Fundamental Research Funds for the Central Universities No.2012QNZT203. No conflict of interests exists.
Correspondence: Xingli Li, School of Public Health, Central South University, No. 110 Xiangya Rd, Changsha, Hunan 410078, People's Republic of China. E-mail: email@example.com.
Received for publication January 4, 2012, and accepted April 17, 2012.
A number of evidence suggests the recent increased proportion of persons aged 50 years or older among the HIV-infected population.1 Between 2000 and 2007, in the European regions, the number of new HIV diagnoses doubled among older adults.2 Between 2003 and 2006, in the United States, the HIV prevalence among old individuals increased from 20% to 25%.3 Based on China CDC's statistics, the prevalence of HIV/AIDS infections increased from 7.8% in 2006 to 14.9% in 2009 among elders.4 This recent worldwide rise may be in part due to the extension of life expectancy as the result of the implementation of highly active antiretroviral therapy and the increase of newly acquired infections. Unfortunately, the elders have been seldom recognized as high-risk group for HIV infection.
The exploration of detailed epidemiologic characteristics of older HIV-positive persons will be helpful for understanding the recent rise. Limited studies built associations between HIV infection and unsafe sexual behavior and lack HIV prevention knowledge for the elderly.5–8 However, the epidemiologic characteristics remain unknown for older HIV-infected persons in China. In this article, we conducted a cross-sectional investigation into the likely transmission mode and associated factors of HIV infections among older adults aged 50 years or older.
MATERIALS AND METHODS
Definition of Older Adults
Older adults were defined as individuals aged 50 years or older at the time of HIV/AIDS diagnosis.8,9
Hunan is a landlocked province located in South Eastern China. The study was conducted in 4 counties of Yongding, Sangzhi, Cili, and Jishou of Hunan Province. All of 4 counties are located in the remote west mountainous region that is heavily populated by ethnic minorities. These 4 counties comprised 63.4% of all HIV-positive cases aged 50 years or older for Hunan Province in 200810 and had significantly increasing HIV-positive case rate from 2005 to 2008.
All of participants were identified through the Hunan HIV/AIDS Registry System. According to the data of 2008, 109 HIV-positive cases aged 50 years or older were found in the 4 selected counties. Of them, 80 cases were alive when recruited into this study, including 5 couples. All of 80 cases agreed to participate in this study.
When the suspected HIV-positive cases were initially detected, they would be reported to local CDC where the HIV antibody was tested using the enzyme-linked immunosorbent assay and an HIV-1/2 Western Blot immune assay. At the same time, the CD4 counts of HIV-positive persons were also tested. All of relevant personal information was entered into the HIV registry system of local and Hunan Provincial CDC. In China, HIV test is offered only to patients who need surgery or blood transfusion or who have signs and symptoms of HIV/AIDS at hospitals.
Only 1 of 80 participants was found through self-requested HIV test, 47 cases were detected in the tests for operations. Another 32 cases were diagnosed by the active HIV test at local CDC because their spouses were found to be HIV-positive.
Because of illiteracy, participants were surveyed by face-to-face interviews. Each interview lasted about 45 minutes to an hour. At the beginning of the study, interviewers introduced the aim, procedure, and plan to every participant. Every volunteer participant pressed his fingerprints on the information consent form before the formal survey. Because the subjects were primarily minority population, the interviews were conducted by experienced health care professionals working for the local CDC who were from the same population in ethic minority dialect. Before the survey, all interviewers received training on communication skills and protection of human subjects.
On the basis of previous research, we developed the survey questionnaire, including (1) demographic and socioeconomic characteristic (age, ethnicity, education, marital status, housing status, income); (2) sexual behaviors, including marital sex (sexing frequency after 50 year old, sexual satisfaction, condom use with spouse and commercial sex workers [CSWs] before and after HIV diagnosis, the reason of not using a condom) and commercial sex (commercial sex frequency, gender of commercial sex partner, health status of commercial sexual partners, condom use, the reason of not using a condom, sex acts performed, venue location for CSWs, cost, the reason of purchasing sex); (3) knowledge and channel of HIV/AIDS/STIs, including the transmission mode of HIV, prevention methods, clinic symptoms; (4) other risk behaviors, including illegal drug (heroin, cocaine, marijuana) and mode of use (orally, smoked, injected) and history of blood transfusion.
In addition, we also collected the infection status of participants' spouses and the baseline CD4 counts of all participants. The infection information of participants' spouse was collected through asking the participants and double checking with the information from the local CDC. In China, if the husband or wife was found to be HIV positive, the local CDC will provide free HIV test for their spouses and put them under the formal charge of HIV-positive cases. Confidentiality of personal information was protected. In our study, the baseline CD4 counts of participants were extracted from the history records of the HIV/AIDS Registry System.
The study protocol was approved by the Institutional Review Board of the Hunan Branch of China Preventive Medicine Association and conducted between March and July 2009.
All data were double entered and validated in Epi-Data version 3.0. The analyses were performed using SPSS for Windows, version 13.0. We used the x[Combining Macron], s to describe quantitative data and used proportion, median, and quartile to describe the qualitative data.
Sociodemographic Characteristic of Participants
A total of 80 participants were interviewed. Forty-six of them (57.5%) were men. Ages of participants ranged from 51 to 82 years. Twenty-three percent (18/80) of participants were between 50 and 60 years of age, 45.0% were between 60 and 70 years of age, and 32.5% were older than 70 years of age. The average age was 65.2 (SD: 7.2). Sixty-one participants (76.3%) were Tujia minorities. Forty-five percent were widowed and divorced (Table 1).
Baseline CD4 Counts and Mean Age at the HIV Diagnosis
Table 2 showed that 20 men (44.7%) and 10 women (31.0%) had CD4 counts <200 cells/mm3. The mean age of them at diagnosis was 70 years and 61 years old, respectively. In all, 26 men (55.3%) and 24 women (69%) had CD4 counts ≥200 cells/mm3. According to the mean incubation period of HIV infection progressing to AIDS, most of participants were infected with HIV after 50 years of age.
One case had a history of commercial blood donation in 1981. Eight reported to have received the blood transfusion, 3 before 1976 and 5 after 1984. Of 46 male participants, 45 (98.0%) reported to have sexual intercourse with CSWs before their HIV diagnosis. None of the female participants reported to have engaged in commercial sex activities. None of the participants reported to have injected drugs (Table 3).
HIV Status of Participants' Spouses
Among the 46 female spouses, 33 received HIV testing and 16 (48.5%) were found to be HIV-positive. Among the 34 male spouses, 91.2% (31/34) received HIV testing and 27 (87.1%) were found to be HIV positive (Fig. 1).
Marital Sex and Condom Use
Thirty-eight of 46 male participants (82.6%) and 26 of 34 female participants (76.5%) reported to have more than one time sexual intercourse per month with their marital partners after being 50 years old. Ninety percent reported not having marital sex after being separated, widowed, or after loss of libido. The average age of participants who reported not having sexual intercourse with their marital partners was 60.5 (SD: 8.9).
None of the participants reported using condoms during sexual intercourse with their marital partners before knowing their HIV status because they thought that other contraceptive measures were adequate (45.0%), or they did not perceive themselves at risk of HIV/AIDS/STIs and were unaware that condoms were a method to prevent HIV/STIs transmission (55.0%). After knowing their HIV-positive status, 5 positive couples still reported to have unprotected sex.
Commercial Sex and Condom Use
Among the 45 male participants that had sexual intercourse with CSWs, 15.8% (7/45) reported to visit CSW once, and 84.2% of them reported more than 2 times before knowing their HIV-positive status. The mean frequency of seeking sex with CSWs was 4. All of the CSWs were female. The average age of the first and the last sexual encounter with the CSWs was 56.9 (SD: 10.6) and 64.2 (SD: 7.9), respectively.
Among the male participants who had sexual intercourse with CSWs, 97% reported never using condoms. Also, 90% were unaware that they should use a condom, and 7.0% thought it was unnecessary.
Factors Associated With Commercial Sex
Participants reported having sex with CSWs because they were unsatisfied with their marital sex (76.3%) or were approached by CSWs (23.7%). Seventeen male participants still reported having strong libido after knowing their HIV-positive status, and 64.7% (11/17) of them had sex with CSWs to satisfy their libido without using a condom. They knew where to find CSWs through friends (44.8%) or approached by CSWs (55.2%). Usually, they found CSWs in small rented houses near crowded market vendors and paid 5 to 20 RMB ($1 to $3 USD) for each sexual encounter.
HIV/AIDS and STIs Knowledge
Of the participants, 82% did not know that condoms could prevent HIV/AIDS/STIs and two-thirds never heard of HIV/AIDS before HIV diagnosis. In addition, 14% of participants knew HIV could be transmitted by sex, 11% through blood, and 4% from mother to child (Table 4).
Our study results showed that heterosexual transmission was the likely mode of HIV/AIDS infection among Chinese older adults in rural areas. For male older adults, the transmission mode of HIV/AIDS was mainly from unprotected sexual intercourse with CSWs. For older women, the main mode of infection was likely from having unprotected sex with their husbands.
The results suggested that many Chinese older adults remained sexually active, and most of them were infected with HIV/AIDS/STIs after 50 years of age, similar to findings from international studies.11–13 Many older men stopped having marital sex because they became separated, widowed, or their spouse experienced loss of libido after menopause. The strong sexual desire along with the availability of cheap commercial sex may be primary reasons for commercial sex. Hong and Li reported that there are approximately 4 to 10 million CSWs in China.14 According to sentinel surveillance data, the prevalence of HIV/AIDS among CSWs reached 5.2% in some places of Hunan.15 Eighty-two percent of CSWs have the STIs in Cili county.16 Li et al reported that the average rate of using condoms was approximately 38.7% when sex workers have sexual encounters with clients in China.15 Our results showed that the rate of using condom among these low-tier CSWs in rural areas was lower than the average rate, and rural elders are more likely to purchase sex from low-tier sex workers, similar to findings from study by Pearline et al.13 The low proportion of condom use and high prevalence of HIV/AIDS/STIs among CSWs along with the demand for commercial sex from older males could explain the increased HIV infection prevalence among older adults in China.
This study found that almost all of the participants never used a condom during sexual intercourse with their marital partners or commercial sex partners. This may be due to the misleading nature of the word “condom” in Chinese. In Chinese, the word for condom, “bi yun tao,” transliterates into “prevent pregnancy device.” Therefore, people may perceive condoms as a contraceptive device rather than as a method of protecting themselves from HIV/AIDS/STIs.
Ethnic minority in China, many older adults lacked basic health literacy and appropriate channel of obtaining health knowledge. Especially many older adults had limited HIV/AIDS/STIs prevention knowledge. Our study results showed that approximately 50% of male HIV-positive adults contacted with CSWs by the suggestion of their friends. In rural areas, many older adults lack the fun of entertainment and commonly spend time together outside their homes with each other. Peer education may be an effective way to prevent and control HIV/AIDS infection among this group of people.
Currently, educational campaigns focus on younger people and older adults are generally overlooked.1 Furthermore, many people even including health care providers do not perceive older adults as the high-risk population for HIV/AIDS.17 Therefore, further educational campaigns targeting older adults are essentially needed.
There are several limitations of this study. We recruited our participants from an existing HIV/AIDS Registry System with unknown selection biases, although attempts were made to reduce the selection bias by inviting all alive HIV-infected older adults from these regions. Also, sensitive private self-reported information, such as sexual frequencies and condom use, may have information bias.
Despite aforementioned limitations, our study first reported epidemiologic characteristics of older adults with HIV in China and specified the transmission modes and associated risk factors of older Chinese population in rural areas. Our results stress the importance of providing HIV/AIDS prevention program among older Chinese population.
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