Drug Use and Loneliness Are Linked to Unprotected Sex in Older Adults with HIV
Sexually active participants in a survey of HIV-positive adults aged 50 and older in New York City reported practicing a range of risk reduction strategies, and nearly half said they used a condom every time they had sex.1 But 34% reported having recently had unprotected sex, a high-risk behavior that is predicted by drug use with sex (odds ratio, 2.5) and is positively associated with scores on a scale measuring loneliness (1.03). Consistent condom use was the most commonly reported risk reduction strategy and was particularly prevalent among heterosexual men.
The survey, aimed at exploring the sexual and risk-related behaviors of HIV-positive adults aged 50 and older, was conducted among a sample of 640 males, 264 females and 10 transgender individuals from March to October 2005. Those who lived or received outpatient health care in New York City and were proficient in English were recruited from city-based AIDS service agencies and from public and private hospitals.
Survey Participants completed written, self-administered questionnaires that asked gender-specific questions about their sexual behaviors in the past 90 days, including the number of times they had had intercourse (specifically, oral, anal or vaginal; insertive or receptive; and protected or unprotected). They also were asked about their choice of risk management strategies: serosorting (i.e., having unprotected sex with HIV-positive partners, but not with individuals who are HIV-negative or whose status is unknown); always using a condom during sex; and, for men who have sex with men, strategic positioning (i.e., having unprotected receptive sex with partners who are not HIV-positive). Participants were asked if they had used selected drugs within the past three months; had ever received an AIDS diagnosis; had had any of several health conditions in the past year; and lived with a spouse or partner. Finally, using standardized scales, investigators evaluated participants for loneliness and depression.
Participants’ median age was 54 (age range, 50–78). Fifty percent were black, 33% were Latino, 13% were white, and 5% were members of other racial or ethnic groups or refused to answer. Nearly two-thirds reported being heterosexual; 21% had not finished high school, 30% had graduated and 21% had received a college or vocational degree. Sixty-nine percent reported living alone; 15%, with a romantic partner. Half had an AIDS diagnosis, and 67% had been living with HIV for more than 10 years. Most (85%) were taking antiretroviral medications.
Some 50% of participants had been sexually active in the past three months. Of these, 49% reported having had sex at least 2–3 times per week, and 34% reported having had unprotected anal or vaginal sex. Overall, 45% of participants reported using drugs. Gay or bisexual men were the most likely, and women the least likely, to report any drug use (53% vs. 36%) and drug use during sex (45% vs. 24%).
Investigators used multivariate logistic regression analyses that controlled for demo-graphic characteristics, physical and mental health, and substance use to identify predictors of two main outcomes: sexual activity and unprotected anal or vaginal sex in the past three months. Being sexually active was more likely among heterosexual and gay or bisexual men than among women (2.0 and 2.6, respectively). Participants who lived with a romantic partner and those who used drugs also had elevated odds of being sexually active (1.9 and 2.1). Loneliness and being 60 or older were associated with decreased odds of being sexually active (0.97 and 0.6). Loneliness also was associated with increased odds of unprotected sex (1.03), while participants who combined drugs with sex had more than twice as high odds of reporting unprotected sex as those who did not (2.5).
Although participants reported practicing a range of risk reduction strategies, chi-square tests showed variations by gender and sexual identity. The most commonly used strategy was 100% condom use. This approach was reported by 49% of participants, but it was significantly more common among heterosexual men (60%) and women (49%) than among gay or bisexual men (35%). Thirty-eight percent of participants reported having had only HIV-positive partners, a strategy reported more commonly by women (60%) than by heterosexual men (35%) or gay or bisexual men (27%). Eleven percent of gay or bisexual men reported strategic positioning. The proportion of participants who reported serosorting (17%) or no risk management strategy (14%) did not vary significantly by gender or sexual identity.
The researchers note several study limitations, including their use of cross-sectional data, which prohibits causal interpretation of the association between loneliness and sexual risk. Self-reported data could underrepresent sexual or risk-taking behavior. Also, findings from New York City data may not apply elsewhere. Nevertheless, the researchers, comparing their findings with those from earlier studies, stress the need to integrate information about HIV-related risk behaviors and prevention into health and social services for older HIV-positive adults, recognize how loneliness may factor into sexual behavior, and identify the cumulative risks associated with particular risk management strategies.—A. Kott