In this study, marital histories and the frequency of potentially risky relationships differ substantially by race/ethnicity in older adults. Both nonmonogamous partnerships and time spent single are highest among non-Hispanic Blacks and lowest among non-Hispanic Whites. The greater frequency of multiple and new sex partners among Blacks than Whites or Hispanics is a further indicator of potentially heightened HIV/STD risk in this subpopulation. This is particularly true for Black men who report the highest frequencies of both. Although Black men are more likely than other race/gender groups to report having tested for HIV or been recommended an HIV test, testing rates are low across all subgroups, including Black men who report nonmonogamous partnerships.
Consistent with research by Adimora et al.,6,12
we hypothesized that the higher rates of nonmonogamy among Blacks would be partially explained by their greater likelihood of not being in a committed relationship for all or part of the assessment period. However, when we controlled for the number of years spent single, attenuation was only observed in the odds ratios associated with race for males. Conversely, the odds ratios comparing sexually active Black to sexually active White females increased. Given that the nonmonogamous partnerships reported by Black females were largely attributed to partner infidelity, it is possible that those Black females who spent less time single and more time married had a greater opportunity to either experience or discover partner infidelity.
The bivariate associations of attitudes regarding sexual infidelity with race do not support that attitudinal differences account for the observed racial differences in partnership patterns. Instead, it is possible that the factors contributing to non-marriage and delayed marriage among younger Blacks also contribute to marital instability and infidelity among older heterosexual Black couples. These are thought to include high rates of male incarceration that disrupt relationships,29-30
imbalances in the ratios of men to women that may discourage fidelity among Black men,31
un/underemployment of Black men, and a greater tendency for Black men than Black women to partner with other race/ethnicities -- resulting in an even smaller pool of available male partners for Black women.32
The greater imbalance in the number of older women to men among Blacks than among Whites or Hispanics is caused by racial and gender disparities in disease and injury that lead to increased mortality in Black men compared to both Black women and to men of other race/ethnicities.11, 29
Hence, reductions in the gender/race disparities in life expectancies may not only reduce sex-ratio imbalances but also lower racial disparities in risky relationship patterns in older adults.
This study has several limitations. Although these analyses are based on events occurring over time, the data were collected cross-sectionally and through self-report. Some participants may have been unable to recall accurately all sexual partnerships in the last 5 years or the dates for first and last sex, marriage/cohabitation, divorce/separation, and widowhood. Others may have been unwilling to report having a nonmonogamous partner. To address the latter, we conducted sensitivity analyses, treating as “yeses” those responding “don’t know” or “refused” to the question partner infidelity. The resulting multivariate estimates differed little from when these responses were treated as missing. Finally, because sex itself was defined so broadly, some respondents may have included partners with whom they had only engaged in activities posing little-to-no HIV/STD risk. Nevertheless, just 4.6% of NSHAP respondents who reported sexual activity in the prior 12 months, reported never engaging in vaginal intercourse during the time period. Despite these limitations, the NSHAP data provide rare nationally representative data on sexual risk behaviors in a growing at-risk population, making the findings an important addition to the literature on health disparities and HIV/STD risk in older adults.
Our findings point to an important and potentially growing concern for the population, more and more of whom will spend significant periods of their adult lives single. Taboos and misconceptions about later life sexuality may lead health care providers to assume that older people are not at risk and hence to not consider HIV/STDs in their differential diagnoses or discuss preventive measures and HIV screening with them.33-34
Older adults are unlikely to have received comprehensive sexual education or risk-reduction training during their formative years and now may lack the skills to practice safer sex or the risk perception to seek out HIV testing.35-36
The higher rates of illicit drug use in recent than in earlier cohorts of older persons 37
and the small numbers of prevention programs targeting older people 38-39
may also further contribute to increased HIV/STD risk among each “new generation” of older people. Together, these factors highlight the need for increased and tailored services. Our finding that older blacks had fairly low HIV testing rates (although greater than that of whites) is also cause for concern. Although testing rates may increase with CDC’s current guidelines that health care settings routinely offer opt-out HIV testing to patients ages 13-64 years,40
significant barriers to widespread implementation of these guidelines exists.41-44
Furthermore, potentially at-risk adults ages 65 and older may still be missed. Given the differential impact of divorce/separation and partner death among Black couples and the greater prevalence of nonmonogamous partnerships, training and resources for enhancing the ability of providers to effectively offer HIV testing to older populations should particularly target those serving significant numbers of older Black patients.