Increases cases of HIV among elderly Brazilians; understand – 05/27/2023 – Equilibrium and Health

Every Thursday, infectologist Gisele Cristina Gosuen organizes an afternoon coffee to bring together elderly people with the HIV virus. Family, friends and even neighbors are also invited to participate.

“We have a team of medical residents who provide care there, but if I don’t stop by the room, even to say hello, they are not happy”, she jokes.

For 15 years, Gosuen has been coordinating the HIV and Aging Outpatient Clinic at the Escola Paulista de Medicina/University of São Paulo (EPM-Unifesp).

At the service, she accompanies and supports patients who have been living with the virus that causes AIDS for decades — and receives more and more individuals who have been infected after the sixth decade of life.

This work, by the way, reflects a phenomenon that is becoming more and more apparent in Brazil: in the last ten years, the number of individuals aged 60 or over who tested positive for HIV increased more than four times.

“And the causes of this growth are related to many factors”, points out Gosuen, who also coordinates the Comorbidities Committee of the Brazilian Society of Infectious Diseases.

What do the numbers say

Every year, the Ministry of Health publishes the HIV/AIDS Epidemiological Bulletin, which compiles all the statistics on this epidemic in the country.

The document is fundamental to guide the sector’s public policies and to know in which areas or problems the government should focus its efforts.

The latest edition, released in December 2022, reinforces the upward trend in HIV cases among the elderly — despite the general drop in diagnoses in 2020 and 2021, due to the Covid-19 pandemic.

To give you an idea, 360 Brazilians over 60 years old tested positive for HIV in 2011. This rate rose year after year and reached 1,738 in 2019.

Even with all the pandemic crisis of recent years, there were 1,517 HIV diagnoses among older Brazilians in 2021. This represents a fourfold leap in a decade, as you can see in detail in the graph below.

The relative participation of the elderly in the total percentage of new cases also increased. In 2011, 2.6% of all diagnoses occurred in the over-60 age group. They currently account for 3.7% of positive tests for this virus.

Infectologist Marília Bordignon, from the Extension Service for the Care of HIV/AIDS Patients at Hospital das Clínicas de São Paulo, draws attention to another sign that shows the impact of this virus on the older population: over the last decade, the rate of cases per 100,000 inhabitants fell less in this age group.

“Among people aged 60 or over, we even had a reduction in the rate of AIDS diagnoses. But this drop is much smaller than that observed with the other groups”, he highlights.

And this phenomenon can be observed in both men and women, as shown in the two graphs below.

A phenomenon of multiple causes

Doctor Marco Túlio Cintra, vice-president of the Brazilian Society of Geriatrics and Gerontology, believes that, “like everything that involves the elderly, the increase in HIV detection does not have a single explanation”.

“The first factor is related to the low use of condoms in this age group, as there is no longer any concern about pregnancy”, he points out.

Women who have passed menopause, which occurs around the fifth decade of life, stop ovulating. With that, there is no way for them to produce a baby anymore.

It is worth noting, of course, that the use of condoms is not just a contraceptive method to avoid unwanted pregnancies: they are also effective alternatives to prevent many sexually transmitted infections (STIs), such as HIV itself.

The second ingredient on the list is the popularization of remedies against erectile dysfunction, such as Viagra and Cialis. Thanks to these drugs, older men —who tend to have more problems initiating or maintaining an erection— have found a way to prolong their sex life.

“Many older individuals also go through the experience of divorce or widowhood. As a result, they feel freer to have other relationships,” adds Gosuen.

In this area, relationship apps —some of them created specifically for those over 60— facilitated contacts and new experiences.

Experts heard by BBC News Brasil also point out that several people in this age group formed heterosexual families when they were young, but now discover themselves homosexuals or bisexuals – and some also feel more comfortable having experiences with partners of the same sex at this stage of life.

Fourthly, Bordignon explains that there is a physiological reason that increases the risk of infection at older ages. “We have biological issues that lead to greater fragility of the mucosa [da vagina ou do ânus] and a reduction of the defense system in these places”, he says.

The little lubrication and the fragility of the body’s barriers, which become more common with aging, therefore, facilitate the entry of HIV – if the partner has the virus and preventive strategies are not used, of course.

A fifth aspect raised by the researchers is the increase in testing efforts. That is, did an increase in requests for tests to catch the virus generate an increase in diagnoses?

The information is a little fuzzy in this area. On the one hand, there is indeed an increase in HIV tests across the country, which contributes to the rise in epidemiological bulletins. On the other hand, the elderly are not always included in these tracking and early detection efforts.

“Even when the elderly person already has symptoms, such as severe weight loss, doctors will always suspect cancer, but never the HIV virus”, laments Cintra, who is also a professor at the Federal University of Minas Gerais (UFMG).

“This subject is still a taboo within the offices, as if the elderly do not have a sex life and libido. This is a myth”, admits the geriatrician.

“With that, we lost the opportunity to provide adequate guidance on prevention or make an early diagnosis”, he laments.

“The point is that, ten years ago, it was unusual to find an HIV-positive elderly person. Today, it is not so rare anymore.”

Social scientist Alexandre Grangeiro, a researcher at the Faculty of Medicine of the University of São Paulo (FMUSP), points out that the generational issue should also enter into this equation.

“The generations that preceded the start of the AIDS epidemic in the 1980s, that is, who started having sex before that, were born and educated within a much more liberal process from the point of view of sexual relations and with few preventive care habits. “, analyses.

“Later generations, who started having sex in the 1980s or later, will naturally think more about self-care,” he compares.

Grangeiro also recalls that, with aging, it is common for people to have more contact with health services —which in a way facilitates the diagnosis of diseases.

Finally, experts list an eighth factor that brings together all of the above: the lack of specific awareness campaigns for this audience.

“Communication has always been aimed at specific groups, such as younger people, or events, such as Carnival. As a result, the elderly are not always represented in HIV prevention campaigns”, points out Cintra.

the first impact

Gosuen reports that, in general, the reaction to a positive test for HIV can vary according to gender.

“Older women are usually infected by their husbands, who had some extramarital relationship and brought the virus home. There are also those who separated or became widows and started going out with someone else”, she observes.

“The reaction is one of fright and deep sadness, as they did not see any risk”, he adds.

Among men, Gosuen reports that he witnesses feelings of shame more frequently.

“This occurs mainly when the patient is with a family member or needs to share the news with close relatives.”

The infectologist points out that, not infrequently, the social circle automatically rules out any possibility of the older person having an active sex life.

“Some family members question: but how does my father have HIV if he became a widower 20 or 30 years ago?”

“In both sexes, that thought persists of ‘this will never happen to me’.”

The good news is that today there are quite effective treatments: the so-called antiretroviral therapies make it possible to control the load of the virus, although they are not yet able to eliminate it completely from the body.

But the use of these drugs has some peculiarities in this age group. “It is common for the elderly to have comorbidities and chronic diseases”, details Cintra. With this, doctors adapt the treatment and choose certain drugs that do not harm the functioning of the kidneys, heart or bones.

Sometimes it is also necessary to adjust the dosages or active ingredients used to control other illnesses, such as hypertension, high cholesterol, diabetes…

“The objective of this is not to affect the effectiveness of the antiretroviral therapy, which would make the patient have a higher viral load”, adds the geriatrician.

The HIV prevention mandala

Gone are the days when condoms were the only focus for preventing HIV or other STIs. The most modern way of dealing with the subject is the “combination prevention mandala”.

The method, which has the endorsement of the Ministry of Health itself, points out that there are several strategies to prevent infection by this virus —and it may be that a person adapts better to one method or another (eventually, it is necessary to make a combination of several from them).

The components of this mandala include:

• Use a male or female condom or lubricating gel;
• pre-exposure prophylaxis (Prep);
• Post-exposure prophylaxis (PEP);
• Regular testing for HIV and other STIs;
• Treat all people living with HIV/AIDS;
• Harm reduction;
• Prevent vertical transmission (from mother to child during pregnancy or childbirth).

But what about the elderly? In recent years, a team of Brazilian researchers has created a specific prevention mandala for the elderly – the study that supported the initiative was published in September 2021 in the academic journal The Lancet Healthy Longevity.

In addition to calling attention to methods that are suitable for all ages —such as condoms, PrEP, PEP and the availability of tests— the researchers have given a lot of emphasis to two aspects that become more prevalent from the sixth decade of life onwards. .

“Access to lubricants is essential to counteract that fragility of the mucosa”, cites Bordignon.

“The other point is the menopause genitourinary syndrome, which leaves the woman’s genital region more dry and with microfragility that facilitate transmission”, adds the infectologist.

Therefore, when we talk about the elderly, the use of lubricants during sexual intercourse is essential — not only from the point of view of pleasure, but also from the prevention of STIs.

In addition to individual care, Grangeiro reinforces the need for more inclusive campaigns. “They need to have this generational character, because we are talking about very different audiences”, he considers.

The expert also believes in the importance of adjusting certain aspects of relationship apps.

“They have become a great public square for partners to meet. And these systems need to fulfill the responsibility and social role they have for taking care of people’s health and providing clearer information about STIs”, he opines.

“We should also have clearer policies that offer the best preventive method to each person according to their needs”, evaluates Grangeiro.

“That is, we need to say more clearly that people who cannot or do not want to use condoms properly should seek Prep, for example. This is not done in the most appropriate way and should include all audiences, regardless of age group”, concludes.

– This text was published in