Psychosocial Predictors and HIV-Related Behaviors of Old Adults Versus Late Middle-Aged and Younger Adults

Abstract

Objective: We investigated the psychosocial predictors and HIV-related behaviors of old adults versus late middle-aged and younger adults. Method: A demographically representative sample of residents in Italy aged 18 to 75 years (n = 2,018) was subdivided into three age groups: (a) younger adults (18-49 years), (b) late middle-aged adults (50-59 years), and (c) old adults (60-75 years). Interviews were conducted using computer-assisted telephone survey methodology. Results: Despite reporting similar levels of sexual risk behaviors, late middle-aged and old adults were less likely to use condoms and to have ever had an HIV test. The levels of HIV/AIDS knowledge, risk perception, perceived behavioral control, and behavioral intentions toward condom use were lower among old adults compared with younger adults. Old adults were less likely to have discussed HIV/AIDS with friends, relatives, or health professionals. Discussion: Old adults should be included in prevention efforts targeting knowledge, perceptions, and intentions toward condom use. Future studies should be cautious when overgeneralizing the results to all individuals aged 50 and older.

Keywords

HIV/AIDS survey sexual behavior risk perception knowledge older adults Theory of Planned Behavior

In Western and Central Europe, an estimated 30,000 people were newly infected with HIV in 2011, and in the same year, 900,000 adults and children were living with HIV infection (UNAIDS/World Health Organization [WHO], 2012). Given the absence of a decline in the number of cases being diagnosed each year and an estimated rate of 5.7 cases in every 100,000 people, HIV continues to be a major public health concern for Europe (European Centre for Disease Prevention and Control/World Health Organization/WHO, 2012). In Italy, the prevalence of people living with HIV/AIDS is around 0.16 among 100 residents (Raimondo, Camoni, Regine, Salfa, & Dorrucci, 2013). Much attention has been given to preventing HIV infections in young adults, yet 12.9% of newly reported cases of HIV infection in Western Europe were in people aged 50 years or older (Lazarus & Nielsen, 2010). In Italy, a percentage of 25.1 of people living with HIV were between 50 and 59 years old, and 8.2% were more than 60 years old (Raimondo et al., 2013).

The number of older adults living in Western countries with a diagnosis of HIV/AIDS has risen in the past decade (Justice, 2010; Lazarus & Nielsen, 2010), and this is due to two main reasons. First, with the introduction of highly active antiretroviral treatment (HAART) in the mid-1990s, life expectancy among people living with HIV has increased significantly. Second, some of the older people living with HIV are those who were infected late in life (Palella et al., 1998).

Although evidence of HIV transmission, high rates of late presentation, and an increased risk of short-term mortality have been found among older adults (Smith, Delpech, Brown, & Rice, 2010), little research attention has been paid to the prevention of HIV to this population of elderly people (Davis & Zanjani, 2012; Milaszewski, Greto, Klochkov, & Fuller-Thomson, 2012).

Despite its considerable relevance (Lazarus & Nielsen, 2010; Smith et al., 2010), little is known about the psychosocial predictors (e.g., HIV-relevant knowledge, risk perception, attitudes, intentions) of HIV-related behaviors (e.g., condom use or HIV testing) of older adults compared with more frequently studied HIV risk groups such as young people, gay men, and injection drug users. This is noteworthy since “prevention and treatment programs, which have been developed with a young population in mind, could be notably less effective for older persons” (Mack & Bland, 1999, p. 687). A review of social and behavioral literature regarding older adults and HIV found that most articles on risk and/or prevention were descriptive in nature and defined their samples as age 50 and older without comparison groups of younger people (Sankar, Nevedal, Neufeld, Berry, & Luborsky, 2011). Moreover, the authors pointed out that only few articles subdivided age 50 and above into subgroups and, because of that, the results were overgeneralized to all individuals aged 50 and above. Although 50 years of age is not a marker of conditions associated with older age, in HIV-related psychosocial research, the term “older adult” has been used to refer to people aged 50 or above, while “younger adult” refers to people younger than 50 (Crystal et al., 2003; Sankar et al., 2011; Ship, Wolff, & Selik, 1991). Specifically, the designation of the age of 50 and above as older adult in relation to HIV/AIDS was based on 1980s Centers for Disease Control and Prevention (CDC) reports (see Sankar et al., 2011). To increment the validity of the findings in the field of aging and HIV and avoid the risk of overgeneralizing the results to all individuals aged 50 and above, in the present study, three age cohorts will be considered: younger adults (18-49 years), late middle-aged adults (50-59 years), and old adults (60-75 years). Therefore, in line with the literature (Crystal et al., 2003; Sankar et al., 2011; Ship et al., 1991), the term older adult will be used to refer to people aged 50 or above, while the term old adult will be used in the present study to refer to people aged 60 to 75 years.

There is some evidence that HIV testing and use of condoms among persons aged 50 and above seem lower compared with younger adults, despite the levels of risk behaviors of older adults being similar to younger adults (Sankar et al., 2011). The first aim of the present study was to compare HIV-related behaviors (i.e., HIV testing, HIV risk behaviors, and use of condoms) between three groups of participants drawn from the Italian general population: (a) younger adults (18-49 years), (b) late middle-aged adults (50-59 years), and (c) old adults (60-75 years).

Among the psychosocial/cognitive predictors of HIV-related behaviors, some research findings have shown that the levels of HIV-related knowledge and HIV risk perception are lower among individuals aged 50 and above compared with younger adults (Sankar et al., 2011). Previous reviews have demonstrated the success of the Theory of Planned Behavior (Ajzen, 1991) as predictor of condom use across studies (Albarracín, Fishbein, Johnson, & Muellerleile, 2001; Bennett & Bozionelos, 2000). In brief, this theory identifies condom use (the behavior) as depending on the strength of an intention whether or not to use condoms. In turn, behavioral intentions are predicted by three variables: attitudes toward the behavior, subjective norms (beliefs about how significant others will evaluate condom use), and perceived behavioral control (individuals’ perceptions of their ability to use condoms). However, no study has compared the differences between old, late middle-aged, and younger adults in intentions, attitudes, subjective norms, and perceived behavioral control toward condom use. The second aim of the study was to investigate age differences in psychosocial/cognitive HIV domain.

The lack of opportunity to discuss HIV-related issues may be one of the reasons why the levels of HIV-related knowledge and HIV risk perception are lower among individual aged 50 and above compared with younger adults. The lack of focus on individuals aged 50 and above in the HIV/AIDS literature suggests ageist assumptions concerning age and sexuality (Emlet, 2006) and significant others including health care professionals may also act on the basis of similar assumptions. For example, older adults are stereotyped as less sexually capable and less interested in sex than younger people; therefore, the HIV risk-related sexual behaviors of older adults may be ignored by family members, health care workers, and society in general. There is evidence that health care providers overlook older people’s risk for HIV/AIDS (Kim et al., 2001; Skiest, Rubinstien, Carley, Gioiella, & Lyons, 1996) and feel discomfort when exploring elderly patients’ sexual behavior (Skiest & Keiser, 1997). Health care professionals’ recommendations are the primary reason for HIV testing among older adults and the failure to recognize the at-risk status of older adults by health care professionals may explain why HIV testing is lower among this cohort of people (Lekas, Schrimshaw, & Siegel, 2005). Based on the above-mentioned evidence, the third aim of the present study was to explore the relationship between the three age groups and opportunity to discuss HIV/AIDS with significant others including health care providers.

Method

Participants and Procedure

Using computer-assisted telephone survey methodology, a sample of 2,018 Italian residents was interviewed. The telephone survey was conducted in October 2012, using random digit dialing. Each interview lasted about 15 min. During the interview, lists of items within sections were sequenced randomly to balance for possible order effects. Proportional quota sampling was used to ensure that respondents were demographically representative of the general population, with quotas based on age group, sex, and region. Of the total phone numbers that were dialed, 0.7% was fax machine, 0.4% was answer machine, 14.5% was not valid, 22.5% was unanswered, 12.8% was no eligible (e.g., company or private firm telephone number or underage respondents), 39.3% resulted in a refusal, 1.3% were addressed to individuals with demographic characteristics of quotas already met, and 8.7% were completed interviews. The total number of calls where potential participants had responded was 11,427 and 2,018 (17.66%) interviews were completed. Although the migrant population was underrepresented, the survey can be considered demographically representative of resident population of Italy between 18 and 75 years of age. Younger adults (18-49 years) were 1,132 (56.2%), late middle-aged adults (50-59 years) were 383 (19.0), and old adults (60-75 years) were 500 (24.8%). The socio-demographic characteristics of the participants by the targeted age groups are shown in Table 1.

Table 1.

Socio-Demographic Characteristics of Participants.

	18-49 years		50-59 years		60-75 years
	N	%	n	%	n	%	χ²	p
Gender							3.865	.145
Male	564	49.9	201	52.5	230	46.0
Female	567	50.1	182	47.5	270	54.0
Level of education							221.322	<.001
Elementary school	9	0.8	18	4.7	91	18.2
Middle school	229	20.3	109	28.5	129	25.8
High school	602	53.3	185	48.4	179	35.8
University	290	25.7	70	18.3	101	20.2
Marital status							104.678	<.001
Unmarried	466	41.2	64	16.7	114	22.8
Married/cohabitating	664	58.8	319	83.3	385	77.2
Employment status							1,317.173	<.001
Retired/unable to work	12	2.7	43	9.6	393	87.7
Student	155	98.7	1	0.6	1	0.6
Unemployed	217	61.6	84	23.9	51	14.5
Employed	747	70.7	254	24.1	55	5.2
Nationality							10.372	.006
Italian	1,101	97.4	380	99.2	497	99.4
Non-Italian	29	2.6	3	0.8	3	0.6
Sexual orientation							3.307	.191
Heterosexual	1,064	94.5	366	96.3	477	96.2
Homosexual/bisexual	62	5.5	14	3.7	19	3.8
Religious faith							3.942	.139
Religious	937	82.8	327	85.4	432	86.4
Not religious	195	17.2	56	14.6	68	13.6

Note. Numbers may not add up to total because of missing values.

Measures

The interview was divided into four main sections: general and demographic information (i.e., gender, age, marital status, level of education, employment status, nationality, sexual orientation, religious faith), psychosocial/cognitive variables (i.e., HIV/AIDS knowledge, risk perception, behavioral intentions, attitudes toward the behavior, subjective norms, and perceived behavioral control), and behavioral HIV variables. The latter included the opportunity to discuss HIV/AIDS with friends, relatives, or health professionals, past risk behaviors (i.e., unprotected sexual intercourse with multiple partners), and preventive behaviors (i.e., HIV testing, condom use).

We used 10 and 4 items measuring HIV/AIDS knowledge and risk perception, respectively. Five questions were taken from the UNAIDS indicators for knowledge of HIV prevention methods and knowledge about HIV/AIDS transmission (UNAIDS, 2010) and five questions from a previous study conducted in Italy (see Prati, Mazzoni, & Zani, 2014). Correct responses were recoded as 1, while incorrect responses were recoded as 0. Then all 5 items were added to form an HIV/AIDS knowledge index that ranged from 0 (low knowledge) to 10 (high knowledge). The measure of risk perception was derived from a previous study conducted in Italy (Prati, Pietrantoni, & Zani, 2011). Item examples were “Do you think you are at risk of getting HIV infection?” and “Are you worried about HIV/AIDS?” Responses on risk perception were provided using a 10-point Likert-type scale (1 = not at all, 10 = extremely). The items were averaged to an overall measure of risk perception. Cronbach’s alpha for this scale was acceptable (.74).

Eight questions were based on the recommendations for measuring intentions, attitudes, perceived behavioral control, and subjective norms directly (Fishbein & Ajzen, 2010). Two items were used to measure perceived behavioral control using the same stem: “For me to use condom in the next sexual intercourse is” and two kinds of anchors of a scale. Specifically, the respondents were asked to give a number between 1 extremely difficult or impossible and 10 extremely easy or possible, respectively. Attitude toward condom use was measured through two items: “For me, using a condom in the next sexual intercourse is extremely valuable/extremely worthless” and “For me, using a condom in the next sexual intercourse is extremely pleasant/extremely unpleasant.” For both questions, the respondents again had to report a number between 1 and 10. Subjective norms were measured through two items: “Most people whose opinions I value would approve the use of a condom in my next sexual intercourse” (strongly disagree/strongly agree) and “Most people who are important to me think that I should/I should not use a condom in the next sexual intercourse.” For both questions, the respondents again had to report a number between 1 and 10. Intention to use condoms was measured through a couple of items: “I plan to use a condom in the next sexual intercourse” and “I intend to use a condom in the next sexual intercourse.” Participants were asked to report a number between 1 and 10, whereby 1 meant extremely likely or disagree, and 10 extremely unlikely or agree, respectively. These measures were tested by confirmatory factor analysis with the aim of assessing their unidimensionality, convergent, and discriminant validity. Confirmatory factor analysis revealed that these measures had adequate fit (χ² = 114.18, df = 14, p < .001, NFI = .96, CFI = .96; RMSEA = .060). Each pair of items was averaged to form a composite measure.

To measure past sexual behavior at risk for HIV infection, participants were asked if they had unprotected sexual intercourse with multiple partners during the last 4 months (“yes/no”). Furthermore, we were interested in measuring participants’ preventive behaviors. Specifically, participants were asked if they had ever been tested for HIV (“yes/no”) and if they used condoms during the last sexual intercourse (“yes/no”). Finally, we asked participants if, in the last 4 months, they discussed with friends, relatives, or health professionals about HIV/AIDS (“yes/no”).

Statistical Analyses

To investigate the influence of aging controlling for the effects of the other socio-demographic variables, we used logistic and ordinal regression analyses when the dependent variable was dichotomous and non-dichotomous (i.e., ordinal), respectively. Based on Rosenthal’s (1996) guidelines, small, medium, and large effect sizes categories for odds ratios were as follows: about 1.5 to 1 = small effect (i.e., 1.5 or 0.66), about 2.5 to 1 = medium (i.e., 2.5 or 0.40), about 4 to 1 = large (i.e., 4.0 or 0.25).

Results

Age Differences in Socio-Demographic Variables

Table 1 shows the age differences in socio-demographic variables. Compared with older adults, younger adults tended to report a higher level of education, had a higher likelihood to be unmarried, non-Italian, and had a lower likelihood to be retired/unable to work. There were no age differences by gender, sexual orientation, and religious faith.

Age Differences in HIV-Related Behaviors

To address the first aim of our study, we examined age differences in HIV-related behaviors. To control for the effects of gender and the socio-demographic variables found significant in Table 1 (i.e., education, marital status, and employment status) the adjusted association between age and HIV-related behaviors was estimated using multivariate logistic regression modeling. Specifically, the model was estimated including the following independent variables: gender, age, level of education, marital status, and employment status. We did not include nationality because the sample size of non-Italian participants was too small to have satisfactory statistical power. Table 2 shows the differences between the age groups on different behavioral variables. The likelihood of HIV testing was lower in participants aged 60 to 75 years (24.5%) than in those aged 18 to 49 years (44.8%), or between 50 and 59 years (41.9%). Changing the reference category of the logistic regression to participants aged 60 to 75 years confirmed that the likelihood of HIV testing was lower in participants aged 60 to 75 years than in those aged between 50 and 59 years (OR = 1.80, 95% CI = [1.22, 2.66]). The likelihood of condom use at respondents’ last intercourse was higher in participants aged less than 50 years (43.8%) compared with those aged between 50 and 59 years (23.1%) or 60 to 75 years (14.9%). However, there was no significant difference by age groups in recent unprotected intercourse with multiple partners.

Table 2.

Adjusted Odds Ratios [95% Confidence Intervals] for the Associations Between Socio-Demographic Characteristics and HIV-Related Behaviors.

	HIV testing	Unprotected intercourse with multiple partners	Condom use
Gender (female)	1.22 [1.00, 1.49]*	0.34 [0.19, 0.61]**	0.90 [0.71, 1.14]
Age (in years)
18-49	—	—	—
50-59	0.74 [0.58, 0.95]*	1.57 [0.85, 2.87]	0.54 [0.40, 0.74]**
60-75	0.40 [0.27, 0.59]**	1.63 [0.57, 4.62]	0.46 [0.27, 0.77]**
Level of education
Elementary school	—	—	—
Middle school	0.94 [0.58, 1.53]	0.86 [0.23, 3.28]	0.82 [0.40, 1.65]
High school	1.07 [0.67, 1.70]	0.63 [0.17, 2.30]	0.88 [0.44, 1.75]
University	1.49 [0.91, 2.42]	0.64 [0.17, 2.46]	0.93 [0.46, 1.89]
Marital status (married/cohabitating)	1.65 [1.32, 2.07]**	0.22 [0.13, 0.37]**	0.37 [0.28, 0.48]**
Employment status
Employed	—	—	—
Retired/unable to work	0.69 [0.47, 1.01]	0.41 [0.14, 1.24]	0.55 [0.32, 0.94]*
Student	0.24 [0.15, 0.38]**	0.45 [0.18, 1.13]	1.78 [1.12, 2.83]*
Unemployed	0.62 [0.47, 0.81]**	0.64 [0.29, 1.42]	0.90 [0.65, 1.24]

Note. Odds ratios are adjusted for the other predictors in the model.

p < .05. **p < .01.

In addition, the results in Table 2 revealed that the likelihood of HIV testing was higher in female participants, married/cohabitating, and lower among students/unemployed. The likelihood of condom use at respondents’ last intercourse was lower among participants who are married/cohabitating and retired/unable to work, while it was higher among students. The likelihood of unprotected intercourse with multiple partners was lower among female and married/cohabitating participants.

Age Differences in Psychosocial/Cognitive HIV Domain

To address the second aim of our study, we tested for age differences in psychosocial/cognitive HIV domain. Specifically, six ordinal regression analyses were used to test whether or not there were differences on HIV/AIDS knowledge index, HIV risk perception, intentions, attitudes, perceived behavioral control, and subjective norms between the age groups (see Table 3). There was a significant effect of age groups on HIV/AIDS knowledge index, HIV risk perception, intentions, and perceived behavioral control. Specifically, compared with other participants, individuals aged 60 to 75 years reported lower scores on HIV/AIDS knowledge index, HIV risk perception, intentions, and perceived behavioral control. Moreover, scores on intention to use condom were lower in participants aged between 50 and 59 years than in those aged less than 50 years. Finally, the ordinal regression analyses revealed that (a) the HIV/AIDS knowledge index was positively related to the level of education and lower among single and unemployed participants; (b) the levels of HIV risk perception were higher among students, female participants, and those who achieved elementary school; (c) the levels of attitudes toward condom use were higher among female participants and those who achieved a university degree; (d) the scores on subjective norms were higher among female participants and those who achieved elementary school; (e) male participants reported lower perceived behavioral control; (f) the levels of intention to use condoms were higher among students and lower among married participants.

Table 3.

Adjusted Odds Ratios [95% Confidence Intervals] for the Associations Between Socio-Demographic Characteristics and Psychosocial/Cognitive HIV Domain.

	HIV-related knowledge	HIV risk perception	Attitudes	Subjective norms	Perceived behavioral control	Intentions
Gender (female)	0.92 [0.79, 1.08]	1.48 [1.26, 1.73]**	2.01 [1.71, 2.36]**	1.44 [1.22, 1.69]**	1.39 [1.21, 1.60]**	0.93 [0.79, 1.10]
Age (in years)
18-49	—	—	—	—	—	—
50-59	0.85 [0.69, 1.05]	0.81 [0.66, 1.00]	0.98 [0.79, 1.21]	1.11 [0.89, 1.38]	0.86 [0.72, 1.02]	0.78 [0.63, 0.96]*
60-75	0.70 [0.52, 0.96]*	0.65 [0.48, 0.88]**	0.93 [0.68, 1.26]	0.90 [0.66, 1.24]	0.68 [0.52, 0.88]**	0.47 [0.34, 0.64]**
Level of education
Elementary school	—	—	—	—	—	—
Middle school	2.76 [1.90, 4.01]**	0.68 [0.47, 0.98]*	0.85 [0.59, 1.23]	0.59 [0.41, 0.87]**	0.91 [0.67, 1.23]	0.99 [0.68, 1.44]
High school	5.44 [3.77, 7.84]**	0.57 [0.40, 0.81]**	0.89 [0.63, 1.28]	0.55 [0.38, 0.79]**	0.83 [0.61, 1.12]	0.88 [0.62, 1.27]
University	9.17 [6.22, 13.52]**	0.44 [0.30, 0.63]**	0.68 [0.47, 0.99]*	0.45 [0.31, 0.67]**	0.83 [0.60, 1.13]	0.88 [0.60, 1.28]
Marital status (married/cohabitating)	1.24 [1.03, 1.49]*	0.72 [0.61, 0.87]**	0.86 [0.72, 1.03]	1.10 [0.92, 1.32]	0.90 [0.77, 1.05]	0.63 [0.53, 0.76]**
Employment status
Employed	—	—	—	—	—	—
Retired/unable to work	0.92 [0.68, 1.26]	1.03 [0.76, 1.40]	1.17 [0.86, 1.59]	1.02 [0.74, 1.40]	1.17 [0.90, 1.52]	0.78 [0.57, 1.07]
Student	0.81 [0.59, 1.13]	1.48 [1.08, 2.03]*	1.36 [0.99, 1.88]	1.14 [0.82, 1.57]	1.05 [0.80, 1.37]	1.72 [1.23, 2.39]**
Unemployed	0.66 [0.53, 0.83]**	1.24 [0.99, 1.55]	0.99 [0.79, 1.23]	0.90 [0.71, 1.13]	0.86 [0.71, 1.03]	0.91 [0.73, 1.14]

Note. Odds ratios are adjusted for the other predictors in the model.

p < .05. **p < .01.

Age Differences in Discussion of HIV/AIDS

Finally, with respect to the third aim of the present study, we investigated age differences in the likelihood to discuss HIV/AIDS with significant others including health care providers. Results showed that only 6.6% of the participants aged 60 to 75 years discussed with friends, relatives, or health professionals about HIV/AIDS, while the percentage was 16.1% and 13.4% for participants aged less than 50 years and among those aged between 50 and 59 years, respectively. The results of the ordinal regression analyses examining the relationship between age and the likelihood to discuss HIV/AIDS with significant others controlling for the effects of the other socio-demographic variables are shown in Table 4. Participants aged 60 to 75 years were 2 times less likely to have discussed HIV/AIDS with significant others compared with those aged less than 50 years. The likelihood to discuss HIV/AIDS with significant others was higher among female and retired/unable to work participants.

Table 4.

Adjusted Odds Ratios [95% Confidence Intervals] for the Associations Between Socio-Demographic Characteristics and Discussion of HIV/AIDS.

	Discussion of HIV/AIDS
Gender (female)	1.32 [1.02, 1.75]*
Age (in years)
18-49	—
50-59	0.70 [0.63, 1.28]
60-75	0.53 [0.29, 0.92]*
Level of education
Elementary school	—
Middle school	1.21 [0.55, 4.00]
High school	1.64 [0.79, 5.10]
University	2.19 [1.04, 7.21]
Marital status (married/cohabitating)	1.08 [0.80, 1.48]
Employment status
Employed	—
Retired/unable to work	2.20 [1.10, 4.77]*
Student	0.78 [0.39, 1.47]
Unemployed	1.41 [0.79, 2.59]

Note. Odds ratios are adjusted for the other predictors in the model.

p < .05. **p < .01.

Discussion

In the present study, the aims were to examine the differences in attitudes, subjective norms, perceived behavioral control, and intentions regarding condom use, HIV/AIDS knowledge, risk perception, and opportunity to discuss HIV/AIDS with friends, relatives, or health professionals. Specifically, we compared three groups of participants drawn from the Italian general population: (a) people aged 18 to 49 years, (b) people aged 50 to 59 years, and (c) people aged 60 to 75 years. The results extend the findings of previous studies on HIV infection among older people in different ways.

All the results about age differences were controlled for demographic variables like gender, education, marital status, and employment status. Differences in such demographic variables were quite mixed but partially confirmed previous results (Signorelli et al., 2006) suggesting that Italian women are more aware of HIV/AIDS (i.e., higher: HIV risk perception, attitudes toward condom use, subjective norms, perceived behavioral control, discussion about HIV/AIDS) than men, and this is confirmed also at a behavioral level (i.e., HIV testing and lower likelihood of unprotected intercourse with multiple partners).

Age Differences in HIV-Related Behaviors

The results of the present study suggest that late middle-aged and old adults’ HIV-related sexual risk behaviors may not differ from that of younger adults. Previous studies have already shown that older adults do maintain sexual desires, and can engage in sexual activity including risky HIV-related behaviors (e.g., Gott, 2005). More specifically, we found that the number of people engaging in recent unprotected intercourse with multiple partners is not significantly different between the three age groups. Despite sharing the underlying risk (i.e., recent sexual risk behaviors), late middle-aged and old adults were less likely to use condoms and to have ever had an HIV test. We extended previous observations (e.g., Sankar et al., 2011) by demonstrating that this combination of findings was more noticeable among participants aged 60 to 75 years. We believe there may be several reasons why late middle-aged and old adults were less likely to use condoms or request an HIV test. These differences may be due to potential generational and cohort differences. Specifically, elderly people became adults before HIV/AIDS was a known threat and, a part of them, before the sexual revolution that took place in the second half of the 20th century (Milaszewski et al., 2012). Therefore, old adults may be less likely to adopt and negotiate safe-sex practices. It is worthy to note that among the gay community, a group that has frequently been linked to the HIV epidemic, younger adults reported significantly lower rates of never HIV testing (e.g., Prati, Breveglieri, et al., 2014). These findings seem to suggest that the link between safe-sex practices and age is not merely a matter of birth cohort (i.e., group of people who were born in the same date range), but of social generations, that is cohorts of people who were born in the same date range and shared similar cultural experiences (e.g., being gay or heterosexual in the ’80s). To our opinion, the effect of social generations can be detected by investigating age differences in psychosocial/cognitive HIV domain.

Age Differences in Psychosocial/Cognitive HIV Domain

Our findings revealed that old adults but not middle-aged adults report lower HIV risk perception and HIV/AIDS knowledge. Specifically, these differences were only found for participants aged 60 to 75 years and the levels of HIV-related knowledge and risk perception among participants aged between 50 and 59 years were similar to those aged less than 50 years. The present findings extend prior research that has focused primarily on individual aged 50 years or older (Sankar et al., 2011). These findings may explain why especially old adults tend to report a lower likelihood of condom use and previous HIV testing than younger adults. For instance, old adults may hold the belief that HIV is a young person’s disease or affects “at risk” populations and, therefore, there is no need to use condoms (Orel, Spence, & Steele, 2005). However, the differences between old and younger adults in HIV-related knowledge and risk perception were small in magnitude.

To provide a more explanatory frame for understanding the differences between old and younger adults, we used the key-variables of the Theory of Planned Behavior (Ajzen, 1991): perceived behavioral control, subjective norms, attitudes and intention to use condoms. We found that perceived behavior control and intention to use condoms were lower in participants aged 60 to 75 years. We also note that the differences in perceived behavior control toward condom use were small in magnitude. Conversely, the differences in intention to use condoms were medium in magnitude and significantly differentiated the three age groups from each other. The present findings suggest that intention to use condoms is an important explanatory variable in the difference in condom use between younger and older adults. This is noteworthy, given that the existent theoretical and empirical evidence supports the relationship between intention and behavior (e.g., Webb & Sheeran, 2006).

Age Differences in Discussion of HIV/AIDS

Finally, another explanatory variable used in the analysis is the degree to which significant others (friends, relatives, or health professionals) discussed HIV/AIDS with younger, middle-aged, and old adults. We found that participants aged 60 to 75 years were less likely to have discussed HIV/AIDS with significant others. This finding indicates the importance of these inequalities as factors that influence the promotion of safe sexual behaviors among old adults. The ageist assumptions about sexuality and senility may preclude open discussion of issues pertaining to this topic among older adults (Altschuler, Katz, & Tynan, 2004; Emlet, 2006) and explain the observed high rates of late presentation and increased risk of short-term mortality in this population (Sankar et al., 2011).

Implications and Conclusion

The findings of this study are relevant to policy makers and program managers engaged in AIDS prevention programs given the evidence of HIV transmission, high rates of late presentation and an increased risk of short-term mortality among older adults (e.g., Lazarus & Nielsen, 2010; Smith et al., 2010). Despite the relatively few published interventions aimed at the prevention of HIV among older adults, there is some evidence of their effectiveness (e.g., Davis & Zanjani, 2012; Milaszewski et al., 2012). The findings of the present study indicate that intention to use condoms may play a key role in the prevention of HIV/AIDS among older adults. A previous literature review suggested that to facilitate the translation of intentions into action, practitioners may promote intention stability and implementation intention formation (Webb & Sheeran, 2006). Risk reduction strategies should also pay special attention to the requirements at each life stage. Interventions concerning safer sexual practices among older people must be conducted in a way that addresses biologic events (e.g., erectile dysfunction, menopause), life course changes, and cohort effects (Zablotsky & Kennedy, 2003). Finally, to increase the involvement of health care professionals in the prevention of HIV among older adults, educational interventions should be provided (Altschuler et al., 2004; Davis & Zanjani, 2012; Milaszewski et al., 2012).

In interpreting the results of this study, two limitations should be considered. First, in this study, we relied on self-reported information. Another limitation involved the use of a cross-sectional design that provides only a snapshot of a complicated system of relationships at a single point in time. To address these limits, further studies, based on longitudinal designs and on multiple measures of behaviors, are needed. Despite this, the present results indicate that young and older adults, especially those aged 60 to 75 years, differ in HIV-related knowledge, HIV risk perception, HIV testing, opportunity to discuss HIV/AIDS with friends, relatives, or health professionals, perceived behavioral control, intention of and use of condoms. Nevertheless, contrary to the ageist assumptions, the sexual risk practices of older adults are not particularly different from those of younger adults. These findings support the inclusion of older adults, especially those aged 60 to 75 years, in prevention efforts promoting condom use and HIV test. Finally, the results of the present study revealed important differences between participants aged 50 to 59 years and 60 to 75 years. Therefore, future studies should subdivide participants age 50 and older into subgroups and use caution when overgeneralizing the results to all individuals aged 50 and older.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Italian Ministry of Health—Directorate General for Communication and Institutional Relations (research project: “Valutazione pre–post della Campagna ministeriale Educativo-Informativa 2012 per la lotta all’AIDS”).

References

Ajzen

(1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50, 179-211.

Albarracín

Fishbein

Johnson

B. T.

Muellerleile

P. A.

(2001). Theories of reasoned action and planned behavior as models of condom use: A meta-analysis. Psychological Bulletin, 127, 142-161.

Altschuler

Katz

A. D.

Tynan

(2004). Developing and implementing an HIV/AIDS educational curriculum for older adults. The Gerontologist, 44, 121-126.

Bennett

Bozionelos

(2000). The theory of planned behaviour as predictor of condom use: A narrative review. Psychology, Health & Medicine, 5, 307-326.

Crystal

Akincigil

Sambamoorthi

Wenger

Fleishman

J. A.

Zingmond

D. S.

. . .Shapiro

M. F.

(2003). The diverse older HIV-positive population: A national profile of economic circumstances, social support, and quality of life. Journal of Acquired Immune Deficiency Syndromes, 33(Suppl. 2), S76-S83.

Davis

Zanjani

(2012). Prevention of HIV among older adults: A literature review and recommendations for future research. Journal of Aging and Health, 24, 1399-1420. doi:10.1177/0898264312459347

Emlet

C. A.

(2006). “You’re awfully old to have this disease”: Experiences of stigma and ageism in adults 50 years and older living with HIV/AIDS. The Gerontologist, 46, 781-790.

European Centre for Disease Prevention and Control/World Health Organization. (2012). HIV/AIDS surveillance in Europe 2011. Stockholm, Sweden: European Centre for Disease Prevention and Control.

Fishbein

Ajzen

(2010). Predicting and changing behavior: The reasoned action approach. New York, NY: Psychology Press.

10.

Gott

(2005). Sexuality, sexual health and ageing. Maidenhead, UK: Open University Press.

11.

Justice

A. C.

(2010). HIV and aging: Time for a new paradigm. Current HIV/AIDS Reports, 7, 69-76. doi:10.1007/s11904-010-0041-9

12.

Kim

Lyons

T. M.

Parada

J. P.

Uphold

C. R.

Yarnold

P. R.

Hounshell

J. B.

. . .Bennett

C. L.

(2001). HIV-related Pneumocystis carinii pneumonia in older patients hospitalized in the early HAART era. Journal of General Internal Medicine, 16, 583-589.

13.

Lazarus

J. V.

Nielsen

K. K.

(2010). HIV and people over 50 years old in Europe. HIV Medicine, 11, 479-481. doi:10.1111/j.1468-1293.2009.00810.x

14.

Lekas

H. M.

Schrimshaw

E. W.

Siegel

(2005). Pathways to HIV testing among adults aged fifty and older with HIV/AIDS. AIDS Care, 17, 674-687. doi:10.1080/09540120412331336670

15.

Mack

K. A.

Bland

S. D.

(1999). HIV testing behaviors and attitudes regarding HIV/AIDS of adults aged 50-64. The Gerontologist, 39, 687-694.

16.

Milaszewski

Greto

Klochkov

Fuller-Thomson

(2012). A systematic review of education for the prevention of HIV/AIDS among older adults. Journal of Evidence-Based Social Work, 9, 213-230. doi:10.1080/15433714.2010.494979

17.

Orel

N. A.

Spence

Steele

(2005). Getting the message out to older adults: Effective HIV health education risk reduction publications. Journal of Applied Gerontology, 24, 490-508. doi:10.1177/0733464805279155

18.

Palella

F. J.

Jr. Delaney

K. M.

Moorman

A. C.

Loveless

M. O.

Fuhrer

Satten

G. A.

Holmberg

S. D.

(1998). Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. The New England Journal of Medicine, 338, 853-860. doi:10.1056/NEJM199803263381301

19.

Prati

Breveglieri

Lelleri

Furegato

Gios

Pietrantoni

(2014). Psychosocial correlates of HIV testing among men who have sex with men in Italy: A cross-sectional study. International Journal of STD & AIDS, 25, 496-503. doi:10.1177/0956462413515193

20.

Prati

Mazzoni

Zani

(2014). The Influence of knowing someone with HIV/AIDS on preventive behaviors in Italy. AIDS Care, 26, 292-296. doi:10.1080/09540121.2013.824542

21.

Prati

Pietrantoni

Zani

(2011). A social-cognitive model of pandemic influenza H1N1 risk perception and recommended behaviors in Italy. Risk Analysis, 31, 645-656. doi:10.1111/j.1539-6924.2010.01529.x

22.

Raimondo

Camoni

Regine

Salfa

M. C.

Dorrucci

(2013). Caratteristiche delle persone che vivono con l’HIV e con l‘AIDS in Italia [Characteristics of persons with HIV and AIDS in Italy]. Notiziario dell‘Istituto Superiore di Sanità, 26(7-8), 3-6.

23.

Rosenthal

J. A.

(1996). Qualitative descriptors of strength of association and effect size. Journal of Social Service Research, 21(4), 37-59. doi:10.1300/J079v21n04_02

24.

Sankar

Nevedal

Neufeld

Berry

Luborsky

(2011). What do we know about older adults and HIV? A review of social and behavioral literature. AIDS Care, 23, 1187-1207. doi:10.1080/09540121.2011.564115

25.

Ship

J. A.

Wolff

Selik

R. M.

(1991). Epidemiology of acquired immune deficiency syndrome in persons aged 50 years or older. Journal of Acquired Immune Deficiency Syndromes, 4, 84-88.

26.

Signorelli

Pasquarella

Limina

R. M.

Colzani

Fanti

Cielo

. . . Quarto

(2006). Third Italian national survey on knowledge, attitudes, and sexual behaviour in relation to HIV/AIDS risk and the role of health education campaigns. European Journal of Public Health, 16, 498-504. doi:10.1093/eurpub/ckl024

27.

Skiest

D. J.

Keiser

(1997). Human immunodeficiency virus infection in patients older than 50 years. A survey of primary care physicians’ beliefs, practices, and knowledge. Archives of Family Medicine, 6, 289-294.

28.

Skiest

D. J.

Rubinstien

Carley

Gioiella

Lyons

(1996). The importance of comorbidity in HIV-infected patients over 55: A retrospective case-control study. American Journal of Medicine, 101, 605-611. doi:10.1016/s0002-9343(96)00329-4

29.

Smith

R. D.

Delpech

V. C.

Brown

A. E.

Rice

B. D.

(2010). HIV transmission and high rates of late diagnoses among adults aged 50 years and over. AIDS, 24, 2109-2115. doi:10.1097/QAD.0b013e32833c7b9c

30.

UNAIDS. (2010). Monitoring the declaration of commitment on HIV/AIDS: Guidelines on construction of core indicators—2010 reporting. Geneva, Switzerland: Author.

31.

UNAIDS/World Health Organization. (2012). Global report: UNAIDS report on the global AIDS epidemic 2012. Geneva, Switzerland: Author.

32.

Webb

T. L.

Sheeran

(2006). Does changing behavioral intentions engender behavior change? A meta-analysis of the experimental evidence. Psychological Bulletin, 132, 249-268. doi:10.1037/0033-2909.132.2.249

33.

Zablotsky

Kennedy

(2003). Risk factors and HIV transmission to midlife and older women: Knowledge, options, and the initiation of safer sexual practices. Journal of Acquired Immune Deficiency Syndromes, 33, S122-S130.