In summary, the studies reviewed found older and younger adults engaged in similar HIV risk behaviors, but older adults did not perceive themselves to be at risk for HIV and were reluctant to take preventive measures even after an HIV diagnosis. Until recently, older adults were not interested in learning about HIV risk nor were age appropriate information materials available. Late diagnosis was thought to account for much of the initial excess morbidity and mortality of older adults. This delay may have been partially due to stereotypes held by health professionals that led them to forgo testing their older patients for HIV and, possibly, to under-treat them once diagnosed. Clear age-based differences were identified in the area of adherence, with older adults reporting better adherence to ART than younger adults except when suffering from AIDS-related dementia. Age differences were also identified in the settings and experiences of living with HIV, with older adults scoring equal to or better than younger people on several quality of life indicators. Ethnicity and mode of transmission were more significant in accounting for many differences than chronological age.
The studies highlighted the limits of using chronological age alone. Age did not account adequately for the social and behavioral outcomes of older adults with HIV. The impact of and adjustment to HIV were not uniform across older adults. Researchers described difficult lives often plagued by depression and fear of HIV disclosure but also the significant strength of older adults in coping with HIV. These studies described biases against older adults and the impact of these biases on health outcomes. Except in a few research topics, such as adherence to ART, research designed to find age-related differences in various social and behavioral aspects of HIV had limited success. With some notable exceptions, research designs generally did not conceptualize age other than chronological. Use of age 50 to denote older adulthood limited understanding of the relationship of developmental age, life course stage or biological age and HIV.
There are several limitations to this study. We selected studies with samples defined by age 50, excluding several topically relevant studies with samples outside inclusion criteria. Understandings of the disease and its treatment have changed over time. Thus, findings from samples drawn before ART was available may provide an inaccurate picture of the post-ART situation for older people. We have not examined in detail the methods of the studies discussed, but included both quantitative and qualitative investigations. Our objective was to provide a broad overview of the social and behavioral factors associated with aging with HIV; however, we were restricted by the limits of search engines to identify relevant qualitative studies (Evans, 2002
; Greenhalgh & Peacock, 2005
), which may have enriched our understanding of the challenges faced by older adults and the resources available to them.
In conclusion, to study age and HIV we recommend using the full range of concepts germane to aging to better attend to confounds such as cohort effects. Gerontology has documented the cultural disvaluing of the elderly and the implicit bias this can introduce into care for and research focused on older people and HIV. Luther and Wilkin (2007
, p. 579) call attention to the entrenched nature of this disvaluing in their review of a CDC conducted meta-analysis of 18 HIV prevention programs in which none included older adults and some explicitly excluded them (Lyles et al., 2007
). Research designs exploring cultural attitudes and beliefs associated with aging with HIV should pay attention to the role of health care providers, policy-makers, and the public’s stereotypes about older people. Like the process of aging itself, HIV is shaped more by the individual’s social, physical, cultural, and economic setting than by biological senescence. This review has illustrated that chronological age is less relevant to HIV risk and explanations of excess HIV morbidity and mortality than the influence of social and cultural settings on risk perception, testing behavior and physician practice patterns. We have suggested that HIV researchers might find in gerontology a productive engagement as the field moves forward to address the complex interactions of aging with HIV. The concepts of heterogeneity and ageism borrowed from gerontology as well as the distinctions among different conceptualizations of age may contribute to untangling the complex interrelationships among biological aging, disease process, and the social and behavioral sequelae of aging with a stigmatizing illness.