‘Too old to test?’: A life course approach to HIV-related risk and self-testing among midlife-older adults in Malawi

Abstract

Background Despite the aging HIV epidemic, increasing age can be associated with hesitancy to test. Addressing this gap is a critical policy concern and highlights the urgent need to identify the underlying factors, to improve knowledge of HIV-related risks as well as uptake of HIV testing and prevention services, in midlife-older adults.Methods We conducted five focus group discussions and 12 in-depth interviews between April 2013 and November 2016 among rural and urban Malawian midlife-older ( ≥ 30 years) men and women. Using a life-course theoretical framework we explored how social age is enacted and the implications for HIV testing and sexual risk behaviours. We also explore the potential for HIVST to be part of a broader strategy for engaging midlife-older adults in HIV testing, prevention and care. Thematic analysis was used to identify recurrent themes and variations.Results Life course and aging among midlife-older adults was associated with respectability and participants identified HIV as “a disease of youth” that would not affect them, with age protecting them against high sexual activity, infidelity and sexual risk-taking. HIV testing was felt to be stigmatizing, challenging age norms, threatening social status, and implying “lack of wisdom”. These norms drove self-testing preferences at home or other locations deemed age-gender appropriate. Awareness of the potential for long-standing undiagnosed HIV to be carried forward from past relationships was minimal, as was understanding of treatment-as-prevention. These norms led to HIV testing being perceived as a threat to status by older-adults, contributing to low levels of recent HIV testing in midlife-older adults compared to younger adults.Conclusions Characteristics associated with age-gender norms and social position encourage self-testing but drive poor HIV-risk perception and unacceptability of conventional HIV testing in midlife-older adults. There is an urgent need to provide targeted messages and services more appropriate to midlife-older adults in sub-Saharan Africa. HIVST which has often been highlighted as a tool for reaching young people, may be a valuable tool for engaging midlife-older age groups who may not otherwise test.

“Deadly”, “fierce”, “shameful”: notions of antiretroviral therapy, stigma and masculinities intersecting men’s life-course in Blantyre, Malawi

“…We concur with Johnson and colleagues [39] that aging is primarily studied in the context of epidemiological HIV trends [40,41], and that applying a gendered life-course approach would enhance HIV literature. Yet, beyond HIV-testing we propose to analyze "constructions of "respectable" midlife-older age" [39] vis-à-vis younger age to examine how the life-course affects men's experience of stigma, uptake and adherence to ART in a quest for more targeted services for men.…”

“…We view the "life-course" as a useful concept for studies on men and HIV both for changes within men's own life-course (before and after taking ART) as well as agerelated changes in men's sexual life and standing in society. The life-course has been applied to HIV prevention in terms of vulnerabilities of men and women [38] and HIV testing [39]. We concur with Johnson and colleagues [39] that aging is primarily studied in the context of epidemiological HIV trends [40,41], and that applying a gendered life-course approach would enhance HIV literature.…”

Progress towards the UNAIDS 90‐90‐90 targets among persons aged 50 and older living with HIV in 13 African countries

“…Providers often do not consider older adults to be at risk for HIV so there is hesitation to discuss risk behaviours associated with HIV acquisition, such as inquiring into sexual activity and other risk behaviours, though older adults may have similar risks of HIV infection as younger adults [8,10,11,[38][39][40]. This provider bias combined with a lack of understanding of ongoing transmission risk for HIV infection in this population among both the providers and the older adults results in many missed [41,42]. Many OPLWH will wait to test for HIV until symptomatic which results in a delay in diagnosis of HIV and initiation of ART, resulting in poorer health outcomes [8,38,43].…”

“…This provider bias combined with a lack of understanding of ongoing transmission risk for HIV infection in this population among both the providers and the older adults results in many missed opportunities for HIV testing, access to HIV prevention and initiation and retention in treatment services. Country HIV programmes could benefit from additional strategies to raise awareness among healthcare providers and increase health communication campaigns about testing and existing prevention interventions (such as knowledge of partner HIV status and the use of condoms, PrEP or treatment as prevention [U = U] for discordant couples) targeting older populations in SSA [41, 42].…”