Abstract
BackgroundDespite 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.MethodsWe 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 age is enacted socially and its implications on HIV testing and sexual risk behaviours. We also explore the potential for HIV self-testing (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.ResultsMidlife-older adults (30–74 years of age) associated their age with respectability and identified HIV as “a disease of youth” that would not affect them, with age protecting them against 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 and 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 compared to younger adults.ConclusionsCharacteristics 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.
Highlights
Despite the aging HIV epidemic, increasing age can be associated with hesitancy to test
Late diagnosis and initiation of treatment is common among midlife-older men, who prescribe to traditional views of masculinity and age which view accessing HIV services, including testing, as a threat to their position in community and family life [6, 7]. This trend among midlife-older men may contribute to new infections in younger women in southern Africa where intergenerational relationships have been considered a key driver of the HIV epidemic [8]
Volunteers from intervention communities were trained as community-based distributors (CBDs) responsible for providing HIV self-testing (HIVST) to their neighbours [17, 38]
Summary
Despite the aging HIV epidemic, increasing age can be associated with hesitancy to test. Late diagnosis and initiation of treatment is common among midlife-older men, who prescribe to traditional views of masculinity and age which view accessing HIV services, including testing, as a threat to their position in community and family life [6, 7]. This trend among midlife-older men may contribute to new infections in younger women in southern Africa where intergenerational relationships have been considered a key driver of the HIV epidemic [8]. Declining concerns about unwanted pregnancy, together with minimal public awareness of changes in the demographics of the HIV epidemic [10, 11], may lead to greater willingness to engage in condomless sex with existing or new partners of unknown HIV status [12,13,14]
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