The spirit is willing, but... sex in the HIV-positive over-50s

Although the average age of the HIV-positive population is increasing, in both richer and poorer countries, and though sex between older people has often been cited as a possible risk factor for HIV, there has been surprisingly little investigation into the sex lives of people with HIV who are over the age of 50.

A small qualitative study presented to the Tenth AIDS Impact conference of 38 people with HIV in Montreal, Canada, equally balanced between different affected groups, sought to establish patterns of sexual activity in this population and to ask people about the factors behind their behaviour.

Its primary finding was that HIV-positive people, at least in this group, were having relatively little sex – and not always by choice. It also found clear differences between men and women, gay and straight, and injecting drug user (IDU) and non-IDU respondents.

Presenter Isabelle Wallach of the Clinique l'Actuel in Montreal told the conference that in Canada, in 2008, 15.3% of new HIV diagnoses involved people aged 50 years and over, and one-quarter of the HIV-positive population is now over 50. Her team's study aimed therefore to document the experiences of sex and relationships in a group of people with HIV who were over 50, with a view to shedding light on the intersection of HIV, sex and ageing.

The study consisted of individual semi-structured in-depth interviews, with an average duration of two and a half hours, in 38 people with HIV aged 50-74 years.

Twelve gay men, twelve heterosexual men, and 14 women took part in the study. Twelve participants were of non-white ethnicity and eight had acquired HIV through injecting drug use.

Out of the 38 interviewees, only 13 were currently in a relationship, and while nine said they were happy in it, four stated they were having difficulties in the relationship.

Of the 25 single people, eleven stated that it was their choice to be single, while the other 14 said they were unwillingly so and would like a relationship. There was a clear gender divide here: while seven of the women were single by choice, only one of the men was.

Only five out of the 38 interviewees defined themselves as 'actively sexual' and 17 stated they were not having sex at all. Again, there was a clear sexuality and gender divide here: ten of the 14 women and seven out of eight injecting drug users said they were having no sex, but none of the gay men.

This left 16 interviewees who were having some sex but described their sex lives as "slow or not very active".

The qualitative interviews shed a lot of light on participant's views of sex.

Six stated that fear of transmitting HIV was important to them while four stated the death of a partner to AIDS had changed their attitude towards sex (none of the qualitative attitudes explored are exclusive: participants could hold a number of different attitudes).

Stigmatisation and disclosure was one of the most common reasons cited for problems with sex. One 65-year-old gay man said “Nowadays, sometimes, I meet someone, if I tell him 'I am positive', whoops, he is gone.”

Six stated that difficulties they or their partner had with condoms were a reason they had little sex. One woman (59 years old) said that her male partner had never used condoms, having come out of an 18-year relationship, and could not maintain an erection while using one. A 60-year-old heterosexual man said he had encountered resistance to condom use in female partners: “Some women take it as an insult [when I say] we must have safe sex. One said, 'Who do you think I am?'”

Some people were reconciled to the fact that the need for sex diminishes with age, as does sexual performance. One 62-year-old women in a relationship said: “It's been five years since we met and, you know, it's more 'tenderness love' these days.”

Others were less happy about it. Some mourned the fact that age brings with it less power to seduce: “Once we get older we get less looked at,” said one gay man who had reached that age. Others saw it as outright discrimination: “I have already approached some people and...I get told 'What is it that you want? You're old'”, said one 56-year-old gay man.

Unhappiness about the lack of sex and relationships was, however, balanced in many cases by a positive attitude towards being single and a determination not to let it spoil life. “If you delude yourself about really wanting it, you're more disappointed because you don't have it. If it happens, it happens,” said one 65-year-old gay man. A 53-year-old woman said “You've lived such intense things that it can't be an obsession. You can't want it at all costs ... just being alive is already something.”

With qualitative studies like this, reaching hard conclusions about older positive people and sex is not the point, but Isabelle Wallach commented that the clear gender, sexuality and transmission group divides that came up even in this small study suggested further avenues of exploration. While many participants regarded their sex lives (or lack of them) with detachment, others were struggling with problems of both HIV status and ageing. More research into sexuality in the older person with HIV was warranted.

Wallach I et al. Love and sex life of people living with HIV 50 years and over: a qualitative research conducted among men and women in Montreal. Tenth AIDS Impact conference, Santa Fe, New Mexico, abstract 173, 2011.