Prevention of HIV Among Older Adults Literature Review

Journal of Aging and Health
24(8) 1399 –1420
© The Author(s) 2012
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/0898264312459347
http://jah.sagepub.com
459347 JAH24810.1177/0898264312459347Jo
urnal of Aging and HealthDavis and Zanjani
© The Author(s) 2012
Reprints and permission:
sagepub.com/journalsPermissions.nav
1University of Kentucky, Lexington, KY, USA
2SREB Scholar (Southern Regional Education Board)
3NIH BURCWH Scholar (Building Interdisciplinary Research
Careers in Women’s Health)
Corresponding Author:
Tracy Davis, MA, University Of Kentucky–Gerontology, 740
South Limestone, J 525 Kentucky
Clinic, Lexington, Kentucky 40536-0284, USA
Email: [email protected]
Prevention of HIV
Among Older Adults:
A Literature Review
and Recommendations

for Future Research
Tracy Davis, MA1,2 and Faika Zanjani, PhD1,3
Abstract
Objective: This study reviews the existing literature on the
prevention of
HIV among older adults, including universal and indicated
prevention pro-
grams and prevention strategies.
Method: A literature search was conducted between September
and
October of 2011 to identify studies for this review. Several
different elec-
tronic databases and a combination of keywords were used to
conduct
the search. In addition, the reference section of each article was
reviewed
for additional articles.
Results: A total of 18 articles were identified and reviewed.
Three of the
articles examined universal prevention, five of the articles
examined indi-
cated prevention, and the remainder of the articles provided
strategies and
recommendations for the prevention of HIV among older adults.
Discussion: The existing studies document evidence for
preventing future
cases of HIV/AIDS among older adults. Additional studies and
universal and
selected interventions are needed in an effort to reduce the
number of older
adults being diagnosed with HIV.
at UNIV OF MIAMI on February 17,

2016jah.sagepub.comDownloaded from
1400 Journal of Aging and Health 24(8)
Keywords
older adults, HIV, prevention, intervention
Introduction
In recent years, the number of older adults being diagnosed with
HIV and
dying from AIDS has increased dramatically. Unfortunately,
older adults are
seldom included in prevention efforts, thereby contributing to
the increasing
number of individuals being diagnosed with HIV and AIDS. The
number of
older adults grew 14% each year between the years of 2004 and
2007(Justice,
2010). According to the Centers for Disease Control and
Prevention, approx-
imately 31% of those living with HIV are above the age of 50
(Administration
on Aging [AOA], 2012 citing CDC). It is estimated that by
2015, 50% of
those living with HIV will be above the age of 50 (Effros et al.,
2008). Despite
the increasing numbers of older adults being diagnosed with
HIV there
remain relatively few published studies regarding the prevention
of HIV
among older adults. There are several potential reasons for the
limited number

of published studies: (a) researchers are influenced by societal
norms and
beliefs that people above the age of 50 do not engage in sexual
behavior
(Whipple & Scura, 1996) and (b) difficulties in sampling and
other method-
ological challenges that occur when conducting research
regarding sex and
HIV/AIDS among older adults (Falvo & Norman, 2004).
Older adults with HIV/AIDS represent several categories of
individuals:
long-term survivors who have been taking highly active
antiretroviral ther-
apy (HAART) for a long time, newly diagnosed individuals
above the age of
50, individuals who are not aware that they are infected and are
not engaging
in risky behavior, and those who do not know that they are
infected and are
engaging in activities that place themselves and others at risk
for the disease
(Emlet, Gerkin, & Orel, 2009). Despite common misconceptions
older adults
have similar risk factors for contracting HIV as younger adults
(e.g., unpro-
tected sex or sharing needles). Older adults do maintain sexual
desires, can
engage in sexual activity, and can be intimate with more than
one partner at a
time (Muller, 1997; Whipple & Scura, 1996). Sexual
transmission is the most
common means of exposure to HIV in people above the age of
50 (Chen et al.,
1998; Strombeck, 1993; Whipple & Scura, 1996). Research
indicates that older

adults frequently engage in sexual activity and engage in risky
HIV-related
behaviors, (Gott & Hinchliff, 2001) such as not using condoms.
Despite the
increasing number of older adults being diagnosed with
HIV/AIDS, myths
regarding older adults and relatively infrequent sexual activity,
drug use, and
Davis and Zanjani 1401
other risk taking behavior have led to limited screening and
educational
efforts among older adults (Grabar, Weiss, & Costagliola, 2006;
Mack &
Bland, 1999; Orel, Wright, & Wagner, 2005).
Older adults are often less knowledgeable about HIV/AIDS
(CDC, 2011a),
and, therefore, suffer consequences directly related to the lack
of knowledge.
Furthermore, older adults often have misinformation about HIV
and do not
engage in the appropriate methods of protection. For instance,
many older
adults believe that HIV is a young person’s disease and
consequently are less
likely to use condoms (Orel et al., 2005). Also, the symptoms of
HIV/AIDS
can be very similar to other conditions that occur frequently
among older

adults (Falvo & Norman, 2004). The confusion of symptoms can
lead to inac-
curate or delayed diagnosis of HIV among older adults (Rose,
1995). Research
indicates that late diagnosis, impaired immune response,
toxicities associated
with HAART among older adults, and lack of knowledge about
the efficacy
of treatment among older adults may contribute to high rates of
mortality
soon after diagnosis (Goetz, Boscardin, Wiley, & Alkasspooles,
2001; Mack
& Bland, 1999; Manfredi & Chiodo, 2000; Nokes et al., 2000).
Because of
the potential for rapid transition from HIV to AIDS among older
adults, it is
extremely important for older adults to receive a timely
diagnosis of HIV and
to be adherent to their medications as soon as they are
prescribed.
In spite of the increasing number of older adults, those 50 and
older, being
diagnosed and aging with HIV/AIDS there is little research on
the prevention
of HIV among older adults. In addition, there are few
educational resources
adapted for older adults in an effort to assist with prevention
(i.e., universal,
selected, or indicated) (Orel et al., 2004). Universal prevention
strategies
address an entire population, for instance national, local
community, school,
and neighborhood (IOM, 1997). Selected prevention strategies
target subsets
of the total population that are considered to be at risk for a

specific condition
(IOM, 1997). Indicated prevention strategies are designed for
those who have
a certain condition to prevent further spread of the condition
and complica-
tions that may arise (IOM, 1997). The lack of appropriate
educational inter-
ventions is of significant concern. Due to the increasing number
of older
adults in general, and the increase in HIV-positive older adults
(CDC, 2011b),
it is imperative to increase awareness and management
strategies for the chal-
lenges faced by older adults with HIV/AIDS as well as to
increase universal
prevention efforts (CDC, 2011a). To prevent the current
problem from con-
tinuing, it is essential that interventions for the prevention
HIV/AIDS be cre-
ated for older adults.
Due to the growth of older adults and HIV-positive older adults
(CDC,
2011b), it is imperative to increase awareness of prevention
strategies among
older adults (CDC, 2011a). Accordingly, this investigation
reviews the exist-
ing literature on HIV/AIDS prevention among older adults

including the fol-
lowing: (a) educational interventions (i.e., universal
prevention), (b) strategies
for prevention of HIV among older adults, and (c) indicated
prevention inter-
ventions (e.g., risk reduction). This investigation will aid in
increasing the
awareness of what has already been done regarding HIV
prevention among
older adults, as well as understanding the effectiveness of what
has already
been done prior to establishing further intervention efforts.
Method
A literature search was conducted between September and
October of 2011 to
identify studies for this review. Studies were retrieved from the
following
electronic databases: Academic Search Premier, AgeLine,
PsycINFO,
PubMED, and Google Scholar. Each database was explored
using the follow-
ing or a combination of the following keywords: HIV, AIDS,
education,
intervention, older adults, prevention, knowledge, and risk
reduction. In addi-
tion, the reference section of each article was reviewed for
additional articles.
To be included in this review articles had to meet the following
criteria:
(a) published in a peer-reviewed journal, (b) conducted
interventions focus-
ing on the prevention of HIV/AIDS among older adults (those
50 and older),
(c) conducted assessments of the implemented intervention (if

applicable),
(d) provided strategies and guidelines for prevention of
HIV/AIDS among
older adults (e) conducted in the United States, (f) participants
in the study
were mainly older adults, and (g) were published no earlier than
1996. Studies
were excluded if they did not meet the above criteria.
Data were extracted from eligible studies into a table using
Microsoft
Word. The following data was extracted from each study:
authors, publica-
tion date, study objectives, study population, study location,
study design,
theoretical framework, description of intervention, intervention
outcomes,
and rating based on the Quality Assessment Tool for
Quantitative Studies. In
addition, strategies and recommendations for the prevention of
HIV/AIDS
among older adults was reviewed and summarized. In an effort
to assess the
quality and validity of the studies included in this review we
carefully
reviewed the type of data and the analysis to ensure that they
were appropri-
ate for the type of research being conducted. Furthermore, we
only included
studies that had been reviewed by peers and had been approved
by an
Institutional Review Board.
In addition, we used the Quality Assessment Tool for
Quantitative Studies
developed by the Effective Public Health Practices Project in

Canada. This
tool was used for eight intervention studies evaluated in this
review. This tool
is suitable to be used in systematic reviews of effectiveness
(Deeks et al.,
2003), and can be used for randomized control trials, as well as
quasi-
experimental studies, and uncontrolled studies. The tool
consists of the fol-
lowing eight sections: selection bias, study design, confounders,
blinding, data
collection methods, intervention integrity, and analyses.
However, the final
score is composed of the first six sections only. Each of the six
sections is
given a score of strong, moderate, or weak. Finally each article
is given a
global score of strong (no weak score on any of the six
sections), moderate
(one weak score out of the six sections), or weak (two or more
weak scores out
the six sections).
Twenty-two articles that pertained to HIV/AIDS among older
adults were
found. However, four of the articles were excluded either
because they were
published prior to 1996 or they did not pertain to the prevention

of HIV/AIDS
among older adults. The remaining 18 articles were separated
into three cat-
egories: universal prevention interventions (for those without
HIV) (5), indi-
cated prevention interventions (for those with HIV) (3), and
strategies for
universal and indicated prevention (10). In this article, we
synthesize and
compare the core components of the studies selected for this
review, includ-
ing, when possible, study objective, study population, study
location, study
design, theoretical framework, intervention strategies, and
outcomes. In addi-
tion, we report the rating each intervention study received based
on the
Quality Assessment Tool for Quantitative Studies.
Results
Population Characteristics
The majority of the studies reviewed received a rating of
“moderate,” indi-
cating having only one weakness in the study design (Coleman,
Jemmott,
Jemmott, Strumpf, & Ratcliffe, 2009; Falvo & Norman, 2004;
Lovejoy
et al., 2011; Orel, Stelle, Watson, & Bunner, 2010; Rose, 1996).
Only one
study received a “strong” rating (Illa et al., 2010). Tables 1 and
2 summarize
study information from the five universal interventions and
three indicated
interventions.

The majority of the articles reviewed for this study, whether it
was an
intervention or only provided strategies for prevention, targeted
individuals
above the age of 50. Of the eight studies that evaluated an
intervention, four
consisted of predominately females (Altschuler, Katz, & Tynan,
2004; Falvo
& Norman, 2004; Orel et al., 2010; Rose, 1996) and four
consisted of mainly
1404
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, 6
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m
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, a
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te

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k
(c
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d)

1405
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5%
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, 7
.5
%
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at

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m
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, 5
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, 4
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S$
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,0
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a
nd
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hi
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m
m
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it
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tt
in
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R
ep
ea
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m
ea
su
re
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(p
re
-p
o
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-
po
st
)
N
o
t
id
en
ti
fie
d
Pa
rt
ic
ip
an
ts
r
ec
ei
ve
d
an
H

IV
/
A
ID
S
ed
uc
at
io
na
l p
ro
gr
am
.
Pr
e
an
d
in
it
ia
l p
o

st
t
es
t
w
er
e
ad
m
in
is
te
re
d
o
n
th
e
sa
m
e
da
y
o
f

th
e
pr
o
gr
am
.
In
a
dd
it
io
n,
p
ar
ti
ci
pa
nt
s
w
er
e
as
ke

d
to
r
et
ur
n
to
th
e
lo
ca
ti
o
n
o
f
th
e
pr
o
gr
am

ap
pr
o
xi
m
at
el
y
3
m
o
nt
hs
af
te
r
th
e
pr
o
gr
am
. T

ho
se
w
ho
w
er
e
no
t
ab
le
t
o
r
et
ur
n
w
er
e
as
ke
d
to

m
ai
l i
n
th
e
3-
m
o
nt
h
fo
llo
w
-u
p
m
at
er
ia
l.
Po
st

in
te
rv
en
ti
o
n
te
st
s
co
re
s
w
er
e
si
gn
ifi
ca
nt
ly
h
ig
he

r
th
an
pr
e
in
te
rv
en
ti
o
n
sc
o
re
s
(p
<
.0
01
)
an

d
th
e
in
cr
ea
se
s
w
er
e
m
ai
nt
ai
ne
d
at
t
hr
ee
m
o
nt

h
fo
llo
w
-u
p
(p
<
.0
01
).
M
o
de
ra
te
O
re
l,
St
el
le
,
W

at
so
n,
&
B
un
ne
r
(2
01
0)
D
es
cr
ib
e
th
e
N
o
O
ne

is
I
m
m
un
e
In
it
ia
ti
ve
, a
co
m
m
un
it
y
ed
uc
at
io
n
pa

rt
ne
rs
hi
p
ad
dr
es
si
ng
H
IV
/A
ID
S
am
o
ng
o
ld
er
ad

ul
ts
.
N
=
8
9,
m
ea
n
ag
e
=
7
5,
6
6.
6%
fe
m
al
e,
9

4.
4%
W
hi
te
, 4
.5
%
H
is
pa
ni
c,
1.
1%
B
la
ck
, 5
2%

ei
th
er
lo
w
o
r
po
o
r
SE
S
O
hi
o,
S
en
io
r
C
en
te
r
R

ep
ea
te
d
(p
re
an
d
po
st
t
es
t)
H
ea
lt
h
be
lie
f
m
o
de

l
Pa
rt
ic
ip
an
ts
w
er
e
in
vi
te
d
to
p
ar
ti
ci
pa
te
in
a
6

h
r
ed
uc
at
io
na
l p
ro
gr
am
. T
he
pr
o
gr
am
c
o
ns
is
te
d

o
f
in
fo
rm
at
io
n
o
n
se
xu
al
it
y
in
m
id
dl
e
an
d
la
te

r
ad
ul
th
o
o
d,
H
IV
/A
ID
S,
a
nd
o
th
er
S
T
Is
,
an
d

m
ed
ic
at
io
n
an
d
se
xu
al
it
y.
Pa
rt
ic
ip
an
ts
w
er
e
as
ke

d
to
co
m
pl
et
e
a
pr
e
an
d
po
st
t
es
t.
Pa
rt
ic
ip
an
ts

w
er
e
gi
ve
n
th
e
o
pp
o
rt
un
it
y
to
h
av
e
an
H
IV
te
st

fo
llo
w
in
g
th
e
pr
o
gr
am
.
T
he
w
o
rk
sh
o
p
in
cr
ea
se

d
kn
o
w
le
dg
e
o
f
H
IV
/A
ID
S
am
o
ng
o
ld
er
a
du
lt
s;
ni

ne
p
ar
ti
ci
pa
nt
s
re
ce
iv
ed
a
n
H
IV
t
es
t
an
d
re
su
lt

s
im
m
ed
ia
te
ly
fo
llo
w
in
g
th
e
w
o
rk
sh
o
p.
M
o
de
ra
te

(c
on
tin
ue
d)
T
a
b
le
1
.
(c
o
n
ti
n
u
e
d
)

1406
U
ni
ve
rs
al
p
re
ve
nt
io
n
in
te
rv
en
ti
o
ns
(
n
=
5
)

A
ut
ho
r(
s)
an
d
da
te
o
f
pu
bl
ic
at
io
n
St
ud
y
o
bj
ec
ti

ve
s
St
ud
y
po
pu
la
ti
o
n
St
ud
y
lo
ca
ti
o
n
St
ud
y
de
si
gn

T
he
o
re
ti
ca
l
fr
am
ew
o
rk
D
es
cr
ip
ti
o
n
o
f
in
te
rv
en

ti
o
n
O
ut
co
m
es
R
at
in
g
R
o
se
(
19
96
)
Ex
am
in
e
th
e

ef
fe
ct
o
f A
ID
S
ed
uc
at
io
n
pr
o
gr
am
am
o
ng
o
ld
er

ad
ul
ts
o
n
H
IV
/A
ID
S
kn
o
w
le
dg
e,
pe
rc
ei
ve
d
su

sc
ep
ti
bi
lit
y
to
A
ID
S
an
d
pe
rc
ei
ve
d
se
ve
ri
ty
o
f
A

ID
S.
N
=
3
18
, m
ea
n
ag
e
=
7
5,
7
5%
fe
m
al
e,
6
5%

W
hi
te
, 3
0%
B
la
ck
, i
nc
o
m
e
un
kn
o
w
n
M
ea
l s
it
es
:

se
ni
o
r
ce
nt
er
s,
co
m
m
un
it
y
ce
nt
er
s
R
ep
ea
te
d
cr

o
ss
s
ec
ti
o
n
sa
m
pl
es
(
pr
e
an
d
po
st
t
es
t)
H
ea
lt
h

be
lie
f
m
o
de
l
Pa
rt
ic
ip
an
ts
w
er
e
in
vi
te
d
to
pa

rt
ic
ip
at
e
in
1
o
f
24
, 2
0-
30
m
in
, H
IV
/A
ID
S
ed
uc
at

io
na
l
pr
o
gr
am
. T
he
p
ro
gr
am
s
w
er
e
le
d
by
r
eg
is
te

re
d
nu
rs
es
.
Pa
rt
ic
ip
an
ts
w
er
e
gi
ve
n
a
pa
m
ph
le
t

w
it
h
ad
di
ti
o
na
l
in
fo
rm
at
io
n
ab
o
ut
H
IV
/A
ID
S
an
d

ag
in
g.
A
p
re
a
nd
p
o
st
te
st
w
as
a
dm
in
is
te
re
d
Fo
llo

w
in
g
th
e
A
ID
S
ed
uc
at
io
n
pr
o
gr
am
s
ig
ni
fic
an
t
in

cr
ea
se
s
in
to
ta
l A
ID
S
kn
o
w
le
dg
e
(p
<
.0
01
),
pe
rc

ei
ve
d
su
sc
ep
ti
bi
lit
y
(p
<
.0
1)
,
an
d
pe
rc
ei
ve
d
se
ve

ri
ty
(
p
<
.0
01
).
M
o
de
ra
te
T
a
b
le
1
.
(c
o
n
ti
n

u
e
d
)
1407
T
a
b
le
2
.
St
ud
y
an
d
In
te
rv
en
ti

o
n
C
ha
ra
ct
er
is
ti
cs
o
f
th
e
In
di
ca
te
d
In
te
rv
en
ti
o

ns
In
di
ca
te
d
pr
ev
en
ti
o
n
in
te
rv
en
ti
o
ns
(
n
=
3
)

A
ut
ho
r(
s)
a
nd
d
at
e
o
f
pu
bl
ic
at
io
n
St
ud
y
o
bj
ec
ti

ti
o
n
O
ut
co
m
es
R
at
in
g
C
o
le
m
an
, J
em
m
o
tt
,
Je

m
m
o
tt
, S
tr
um
pf
,
&
R
at
cl
iff
e
(2
00
9)
A
ss
es
s
th
e

fe
as
ib
ili
ty
an
d
ac
ce
pt
ab
ili
ty
o
f
an
H
IV
r
is
k
re
du

ct
io
n
in
te
rv
en
ti
o
n
to
in
cr
ea
se
c
o
ns
is
te
nt
co
nd

o
m
u
se
in
a
sa
m
pl
e
o
f
o
ld
er
H
IV
-p
o
si
ti
ve
A
fr

ic
an
A
m
er
ic
an
m
en
w
ho
ha
ve
s
ex
w
it
h
m
en
.

N
=
6
0
1,
m
ea
n
ag
e
=
5
1,
10
0%
B
la
ck
,
10
0%
m
al

e,
52
%
r
ep
o
rt
ed
an
in
co
m
e
o
f
le
ss
t
ha
n
U
S$
10

,0
00
Pe
nn
sy
lv
an
ia
R
an
do
m
iz
ed
co
nt
ro
lle
d
tr
ia
l(
pr

e-
po
st
-
po
st
)
So
ci
al
c
o
gn
it
iv
e
th
eo
ry
, t
he
th

eo
ry
o
f
re
as
o
ne
d
ac
ti
o
n,
t
he
th
eo
ry
o
f
pl
an
ne
d

be
ha
vi
o
r
Pa
rt
ic
ip
an
ts
w
er
e
ra
nd
o
m
iz
ed
in
to
ei

th
er
H
IV
r
is
k
co
nd
it
io
n
o
r
th
e
he
al
th
c
o
nd
it
io
n.

Ea
ch
c
o
nd
it
io
n
co
ns
is
te
d
o
f
ho
ur
12
0
m
in
s
es

si
o
ns
de
liv
er
ed
o
ve
r
a
4-
w
ee
k
pe
ri
o
d
in
a
c
la

ss
ro
o
m
lik
e
se
tt
in
g
us
in
g
in
te
ra
ct
iv
e
ap
pr
o
ac

he
s.
Pa
rt
ic
ip
an
ts
in
b
o
th
gr
o
up
s
w
er
e
as
ke
d
to

c
o
m
pl
et
e
a
pr
e
an
d
po
st
t
es
t
an
d
a
3-
m
o
nt
h
fo

llo
w
-u
p
qu
es
ti
o
nn
ai
re
.
In
cr
ea
se
s
in
t
he
pe
rc
en

ta
ge
o
f
m
en
in
b
o
th
g
ro
up
s
w
ho
u
se
d
co
nd
o
m

s
co
ns
is
te
nt
ly
o
ve
r
ti
m
e
w
as
r
ep
o
rt
ed
(p
=
0
.0

33
).
A
m
o
ng
th
o
se
w
ho
r
ep
o
rt
ed
in
co
ns
is
te
nt

c
o
nd
o
m
us
e
at
b
as
el
in
e
th
ey
w
er
e
fo
un
d
to

be
5
t
im
es
m
o
re
lik
el
y
to
r
ep
o
rt
co
ns
is
te
nt
c
o

nd
o
m
us
e
at
fo
llo
w
-u
p
as
c
o
m
pa
re
d
w
it
h
th
o
se

in
t
he
co
nt
ro
l g
ro
up
. T
he
pe
rc
en
ta
ge
o
f
th
o
se

w
ho
e
ng
ag
ed
in
se
x
w
it
h
m
ul
ti
pl
e
pa
rt
ne
rs
d
ec

re
as
ed
fr
o
m
b
as
el
in
e
to
3-
m
o
nt
h
fo
llo
w
-u
p.

M
o
de
ra
te
(c
on
tin
ue
d)
1408
In
di
ca
te
d
pr
ev
en
ti
o

n
in
te
rv
en
ti
o
ns
(
n
=
3
)
A
ut
ho
r(
s)
a
nd
d
at
e
o

f
pu
bl
ic
at
io
n
St
ud
y
o
bj
ec
ti
ve
s
St
ud
y
po
pu
la
ti
o
n

St
ud
y
lo
ca
ti
o
n
St
ud
y
de
si
gn
T
he
o
re
ti
ca
l
fr
am
ew
o

rk
D
es
cr
ip
ti
o
n
o
f
in
te
rv
en
ti
o
n
O
ut
co
m
es
R
at
in

g
Ill
a
et
a
l.
(2
01
0)
A
ss
es
s
th
e
ef
fe
ct
iv
en
es
s
o
f

an
in
te
rv
en
ti
o
n
de
ve
lo
pe
d
to
r
ed
uc
e
hi
gh
-r
is
k
se

xu
al
be
ha
vi
o
rs
a
m
o
ng
o
ld
er
H
IV
-p
o
si
ti
ve
p
at

ie
nt
s
in
pr
im
ar
y
ca
re
c
lin
ic
s.
(n
=
1
49
, 4
3.
6%

fe
m
al
e,
.7
%
tr
an
sg
en
de
r,
78
.4
%
B
la
ck
,
14
.2
%
H

is
pa
ni
c,
7.
4%
W
hi
te
,
in
co
m
e
un
kn
o
w
n)
2,
3
Fl
o
ri

da
R
an
do
m
iz
ed
co
nt
ro
lle
d
tr
ia
l
(p
re
-p
o
st
-p
o
st

)
In
fo
rm
at
io
n-
M
o
ti
va
ti
o
n-
B
eh
av
io
r
sk
ill
s
m
o
de

l o
f A
ID
S
ri
sk
b
eh
av
io
r
ch
an
ge
; s
el
f-
ef
fic
ac
y
th
eo
ry

Pa
rt
ic
ip
an
ts
w
er
e
ra
nd
o
m
iz
ed
to
e
it
he
r
th
e
in
te

rv
en
ti
o
n
gr
o
up
o
r
th
e
co
nt
ro
l
gr
o
up
. T
ho
se
in
th

e
co
nt
ro
l g
ro
up
o
nl
y
re
ce
iv
ed
an
e
du
ca
ti
o
na
l

br
o
ch
ur
e.
T
he
in
te
rv
en
ti
o
n
gr
o
up
r
ec
ei
ve
d
th
e

br
o
ch
ur
e
an
d
th
e
pa
rt
ic
ip
at
ed
in
th
re
e
in
te
rv
en

ti
o
n
se
ss
io
ns
t
ha
t
in
cl
ud
ed
H
IV
/A
ID
S
in
fo
rm
at
io
n,

H
IV
an
d
se
xu
al
b
eh
av
io
r,
ha
rm
r
ed
uc
ti
o
n
an
d
as

se
rt
iv
e
co
m
m
un
ic
at
io
n
sk
ill
s.
Pa
rt
ic
ip
an
ts
w
er

e
as
ke
d
to
co
m
pl
et
e
a
ba
se
lin
e
su
rv
ey
a
nd
6
a
nd

1
2
fo
llo
w
-u
p.
A
t
th
e
6-
m
o
nt
h
fo
llo
w
-u
p
pa
rt
ic

ip
an
ts
in
t
he
in
te
rv
en
ti
o
n
gr
o
up
re
po
rt
ed
m
o
re

co
ns
is
te
nt
c
o
nd
o
m
us
e
(p
=
.0
03
)
w
it
h
pa
rt

ne
rs
o
f
al
l
se
ro
st
at
us
. A
t
th
e
6-
m
o
nt
h
fo
llo
w
-u
p

in
di
vi
du
al
s
in
b
o
th
th
e
co
nt
ro
l a
nd
in
te
rv
en
ti

o
n
gr
o
up
re
po
rt
ed
in
cr
ea
se
d
H
IV
k
no
w
le
dg
e
(p
=

.0
11
),
(p
=
.0
00
)
re
sp
ec
ti
ve
ly
;
Se
lf-
ef
fic
ac
y
w
as

n
o
t
in
cr
ea
se
d
in
e
it
he
r
gr
o
up
.
St
ro
ng
T
a
b
le

2
.
(c
o
n
ti
n
u
e
d
)
(c
on
tin
ue
d)
1409
In
di
ca

te
d
pr
ev
en
ti
o
n
in
te
rv
en
ti
o
ns
(
n
=
3
)
A
ut
ho
r(

s)
a
nd
d
at
e
o
f
pu
bl
ic
at
io
n
St
ud
y
o
bj
ec
ti
ve
s
St
ud

y
po
pu
la
ti
o
n
St
ud
y
lo
ca
ti
o
n
St
ud
y
de
si
gn
T
he
o
re

ti
ca
l
fr
am
ew
o
rk
D
es
cr
ip
ti
o
n
o
f
in
te
rv
en
ti
o
n
O

ut
co
m
es
R
at
in
g
Lo
ve
jo
y
et
a
l.
(2
01
1)
A
ss
es
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males (Coleman et al., 2009; Illa et al., 2010; Lovejoy et al.,
2011; Small,
2010). Furthermore, five of the study samples consisted of
greater than 50%
Caucasian participants (Altschuler et al., 2004; Falvo &
Norman, 2004;

Orel et al., 2010; Rose, 1996; Small, 2010), whereas three of
the study
samples consisted of greater than 50%, specifically African
Americans
(Coleman et al., 2009; Illa et al., 2010; Lovejoy et al., 2011).
Three studies
included a very small number of Hispanics (Altschuler et al.,
2004; Illa et al.,
2010; Orel et al., 2010). One study included a small percentage
of Asians
(Altschuler et al., 2004). In addition, the interventions were
evaluated among
retired, (Falvo & Norman, 2004; Small, 2010) low income,
(Altschuler et al.,
2004; Falvo & Norman, 2004; Lovejoy et al., 2011; Orel et al.,
2010; Small,
2010) heterosexuals (Falvo & Norman, 2004; Illa et al., 2010;
Lovejoy et al.,
2011), and homosexuals (Coleman et al., 2009; Illa et al.,
2010).
Intervention Characteristics
The interventions targeted either universal or indicated
prevention among
older adults (Altschuler et al., 2004; Coleman et al., 2009;
Falvo & Norman,
2004; Illa et al., 2010; Lovejoy et al., 2011; Orel et al., 2010;
Rose, 1996;
Small, 2010). Five of the studies evaluated universal prevention
interven-
tions among HIV negative older adults (Altschuler et al., 2004;
Falvo &
Norman, 2004; Orel et al., 2010; Rose, 1996; Small, 2010),
whereas three of
the studies targeted indicated prevention among HIV-positive
older adults

(Coleman et al., 2009; Illa et al., 2010; Lovejoy et al., 2011).
Three of the studies did not mention the use of a theoretical
framework
(Altschuler et al., 2004; Falvo & Norman, 2004; Small, 2010).
The remaining
five interventions used several different guiding theories and
frameworks, for
instance the health belief model (Orel et al., 2010; Rose, 1996),
social cogni-
tive theory, theory of reasoned action, the theory of planned
behavior (Coleman
et al., 2009), motivational interviewing, (Lovejoy et al., 2011)
motivation-
behavior skills model, and self-efficacy (Illa et al., 2010).
The majority of the universal interventions recruited
participants from loca-
tions that serve older adults, for instance senior centers or
recreation centers
(Falvo & Norman, 2004; Orel et al., 2010; Small, 2010). The
majority of the
indicated interventions recruited participants from AIDS service
organizations
(Coleman et al., 2009) or other medical settings. Furthermore,
several research-
ers provided incentives to recruit and retain participants, for
example Orel et al.
(2010) provided refreshments, lunch, and door prizes to
participants.
The most frequently used location for interventions was
community settings,
for instance senior centers, recreation centers, AIDS service
organizations, and

urban medical centers (Coleman et al., 2009; Falvo & Norman,
2004; Illa
et al., 2010; Orel et al., 2010; Rose, 1996; Small, 2010).
However, one inter-
vention took place over the telephone (Lovejoy et al., 2011).
The majority of
the interventions used a repeated measures design, with at least
a pre and
posttest. Three out of the eight intervention studies conducted at
least a 3-month
follow-up (Coleman et al., 2009; Illa et al., 2010; Lovejoy et
al., 2011). The
length of each intervention varied from 45 mins (Falvo &
Norman, 2004) to
3 hrs (Small, 2010). The content in the intervention was
different based on the
intended audience. The interventions that targeted HIV-negative
individuals
focused on topics such as, defining HIV and AIDS, myths
regarding HIV/
AIDS, transmission on HIV, prevention, and testing procedures
(Falvo &
Norman, 2004; Rose, 1996; Small, 2010). The interventions that
targeted
HIV-positive individuals focused on increasing condom use as
means of pre-
venting additional infections and the infection of others
(Coleman et al., 2009;
Lovejoy et al., 2011). One intervention included topics such as

assertive com-
munication with partners and developing tactics to increase
condom use (Illa
et al., 2010). Last, Orel et al. (2010) offered HIV testing on site
immediately
following the completion of the sexual health workshop.
Intervention Effects
The majority of reported intervention effects correspond to the
increase in
general HIV/AIDS knowledge and to the reduction of risky
sexual behaviors
(Coleman et al., 2009; Falvo & Norman, 2004; Illa et al., 2010;
Lovejoy et al.,
2011; Orel et al., 2010; Rose, 1996). For instance, Falvo and
Norman, (2004)
found significant increases in HIV/AIDS knowledge (p < .001)
following
their sex education workshop. In addition, Falvo and Norman
found that the
increases in knowledge were retained at the 3-month follow-up
(p < .001).
The three interventions that targeted HIV-positive individuals
reported
decreases in inconsistent condom use, for instance Illa et al.,
(2010) found a
significant increase in consistent condom use after an
educational intervention
at the 6-month follow-up (p = .003). In addition, there were
reductions in the
percentage of participants who reported having multiple sexual
partners, for
instance Coleman et al. (2009), reported an approximate 30%
reduction
among the participants who reported multiple sexual partners.
Although not

significant, Illa et al. (2010) found reductions in sexual self-
efficacy (partici-
pant’s beliefs about their ability to engage in safe sex) after the
intervention.
Two out of the five educational interventions that targeted HIV-
negative
older adults found significant increases in overall knowledge
following the
intervention (Falvo & Norman, 2004; Rose, 1996) and in one
study the
participants retained their knowledge at the 3-month follow-up
(p < .01)
(Falvo & Norman, 2004). Small (2010) did find that participants
had a high
level of interest in receiving and participating in HIV education
programs (p <
.05). Although not significant, Small (2010) did report an
increase in substan-
tive HIV/AIDS knowledge. Furthermore, Small (2010)
identified three salient
thematic categories relevant to HIV/AIDS prevention messages
as a result of
the focus groups: acknowledgement of risk factors (e.g.,
participants recog-
nized that drug use was a risk factor for older adults), barriers
to HIV/AIDS
education (e.g., lack of appropriate health information in

layman terms), and
suggestions for implementation of HIV/AIDS education
programs (e.g., pre-
senting the information in a location where seniors already
gather). In addition
to increasing general knowledge regarding HIV/AIDS among
participants,
Rose (1996) reported significant increases in perceived
susceptibility
(p < .01) and perceived seriousness (p < .01) of the disease.
Altschuler et al. (2004) found that females (p = 0.23),
Hispanics, (p = .000),
and those who are moderately to very religious (p = .023) were
more likely to
indicate that they would attend an HIV education program when
surveyed
about interest in prevention and education programs.
Furthermore, it was
found that having a relationship with someone with HIV/AIDS
(26%), having
a fear of contracting HIV/AIDS (23%), and having a desire for
updated infor-
mation (36%) were found to encourage participation in
HIV/AIDS education
programs (Altschuler et al., 2004). Altschuler et al. (2004) also
found that as
age increases, the likelihood of indicating that a respondent
would attend an
HIV/AIDS educational program decreases. Following the pilot
test of the
HIV/AIDS educational program participants indicated they
learned that HIV/
AIDS was relevant to their lives, they felt empowered to speak
to their health
care providers regarding their sexual health, and were

appreciative to have
the opportunity to discuss an otherwise taboo topic (i.e.,
HIV/AIDS) with
their peers (Altschuler et al., 2004).
Strategies
Strategies for universal prevention focus on educating older
adults about risk
factors for HIV (Strombeck & Levy, 1998) and also educating
health care
professionals to be able to provide prevention information
effectively to older
adults (Strombeck & Levy, 1998). Orel et al. (2004) suggest
that public health
agencies develop age-sensitive HIV/AIDS educational materials
tailored for
broad and culturally diverse older populations. For example,
educational
materials should be sensitive to different languages, religious
beliefs, sexual
orientation, and generational differences (Agate, Mullins,
Prudent, & Liberti,
2003). Rose (2004) suggests that needs assessments be
performed to aid in
developing meaningful, culturally competent, and age-specific
HIV preven-
tion programs.

Orel et al.(2004) recommend that public health agencies support
research
to study older adults’ sexual practices and drug using behaviors.
In addition,
it is suggested that health care professionals be trained to assess
alcohol and
drug use, and obtain thorough health histories including sexual
and substance
abuse histories from their patients (Williams & Donnelly,
2002). Moreover, it
is recommended that health care professionals provide
HIV/AIDS risk reduc-
tion materials with certain medical regimen, for instance sexual
enhancement
drugs (Orel et al., 2004).
Ory, Zablotsky, and Crystal (1998) recommend that researchers
develop
and test interventions to prevent HIV/AIDS among older adults.
To reach
more older adults educational programs should use titles that
are more accept-
able to older audiences, for instance instead of using the words
HIV/AIDS in
the title, a title such as “Safer Sex After 50” should be used
(Agate et al.,
2003). In addition, educational programs should be incorporated
into other
health related educational programs for adults, for instance
incorporating
AIDS-related topics into a program for women about bone
density and osteo-
porosis (Agate et al., 2003). Furthermore, programs should
match the physi-
cal need and limitations of older adults, for example it is
recommended that

programs be about 15 to 20 mins in length (Agate et al., 2003).
Programs and
interventions should be designed to increase general HIV/AIDS
knowledge
(i.e., appropriate factual knowledge) among older adults
(Altschuler et al.,
2004), but also programs should increase perceived
susceptibility and seri-
ousness of the disease (Orel et al., 2010). Programs should
incorporate peer
educators and offer HIV/AIDS websites that provide links to
existing organi-
zations/agencies that provide information about HIV/AIDS and
aging. Last,
interventions should identify and dismantle ageism in relation
to HIV/AIDS
and highlight the fact that it is never too late to introduce
healthy behaviors,
for instance safe sex practices (Coon, Lipman, & Ory, 2003).
Strategies for indicated prevention focus on the health care
system. For
instance, there is a need to increase the number of HIV-infected
persons who
are aware of their serostatus (Janssen et al., 2001). Furthermore,
it has been
recommended that physicians need additional education
regarding HIV/AIDS
among older adults so that they provide early medical
interventions among
those who are HIV-positive (Levy, Ory, & Crystal, 2003;
Siegel, Raveis, &
Krauss, 1992), including testing, the provision of high-quality
care and treat-
ment, and the promotion of adherence to medications (Janssen
et al., 2001). It

has been recommended that education be increased among HIV-
positive
individuals as a means to decrease engagement in risky
behaviors (Janssen
et al., 2001). In addition, it is suggested that patients be
educated on how to
communicate with health care professionals, ways to improve
adherence, and
information on the effectiveness of medications (Strombeck &
Levy, 1998).
Discussion
The results of this review indicate that despite the increasing
number of older
adults being diagnosed with HIV and dying from AIDS (CDC,
2011b), there
are relatively few published interventions aimed at the
prevention of HIV
among older adults. Yet, the interventions that have been tested
have shown
evidence of effectiveness. The results of this review also
indicate that there
are more articles available that provide strategies for the
prevention of HIV
among older adults than interventions evaluating suggested
strategies, for
instance evaluating intervention in health care settings.

Our review identified 18 articles pertaining to the prevention of
HIV/AIDS
among older adults, reported from 1996 to the present. The
majority of interven-
tions in this review report significant increases in HIV/AIDS
knowledge among
HIV-negative older adults. Similarly, the studies in this review
report significant
risk reduction, specifically consistent use of condoms among
older HIV-positive
adults. In addition, the articles that did not test an intervention
offered numerous
strategies for both universal and indicated prevention among
older adults.
However, the most commonly cited recommendation was to
increase the involve-
ment of health care professionals in the prevention of HIV and
the treatment of
HIV among older adults. Other recommendations include
developing and eval-
uating appropriate interventions aimed at preventing HIV
among older adults.
Although it is encouraging that the majority interventions
identified in this
review were efficacious and target important populations,
several gaps still
remain. Only one intervention specifically targeted African
Americans.
African American men and women are the racial group that is
most affected
by HIV; the CDC reports that in 2009 African Americans
accounted for only
14% of the U.S. population, but accounted for 44% of HIV
infections (CDC,
2012). Hispanics, similar to African Americans, are also

disproportionately
affected by HIV/AIDS. In 2009, Hispanics accounted for 16%
of the U.S.
population but accounted for 20% of new HIV infections (CDC,
2011c).
Only three studies included Hispanics in the intervention,
approximately
14% or less of the total study populations and no study
specifically targeted
Hispanics. Other minority groups, such as Asians and Native
Americans
were mentioned in only two of the interventions and accounted
for 10% or
less of the study population.
The majority of the universal prevention interventions included
mainly
females. In 2009, male-to-male sexual contact was reported as
the most com-
mon methods of transmission, (CDC, 2011b), yet no studies
identified in this
review targeted homosexual or nonidentified gay males for
universal preven-
tion. The indicated prevention interventions focused on sexual
behavior as a
means of risk reduction (e.g., condom use or multiple sexual
partners); how-
ever, injection drug use also increases an individual’s risk for

HIV (Linsk,
2000) and therefore should be included in indicated prevention
efforts.
Many of the interventions reviewed did not use randomized
controlled or
controlled study designs, nor was clear whether or not the
measures used to
evaluate the interventions were valid or reliable; this caused
many of the
interventions to obtain a rating of moderate or weak based on
the Quality
Assessment Tool for Quantitative Studies. Universal, selected,
and indicated
prevention intervention could benefit from using stronger study
designs.
Both universal and indicated prevention interventions should
include mul-
tiple methods of reducing risks. Several of the indicated
prevention interven-
tions included information on the importance of being adherent
to anti-HIV
medications. Universal prevention interventions should include
information on
the success of medications in maintaining the health of those
with HIV to
emphasize the point that HIV is no longer a death sentence and
that early detec-
tion and treatment are essential to the successful management of
the disease
(Janssen et al., 2001). Also, similar to one of the indicated
prevention interven-
tions, universal interventions should include information
regarding communi-
cation and negotiations with sexual partners to increase safe

sexual practices,
for instance consistent condom use (Illa et al., 2010). Last, it is
not clear from
the information provided in the articles identified for this
review whether or not
rural areas were targeted locations for interventions. Rural areas
are often over-
looked for HIV prevention (CDC, 2010); however they should
be included in
all forms of prevention interventions as HIV can effect
individuals in rural
areas as well as those in urban areas.
Like other systematic reviews of intervention studies and
strategies for
interventions, this review has its limitations. First, a more
extensive list of
key search terms or a different combination of search terms
could have
yielded additional articles to include in this review, for instance
using the
term aging. In addition, the inclusion of more search engines
may have
yielded more articles for review, such as EBSCOhost or Web of
Science.
Future research should explore these areas to increase the
awareness of what
has already been done regarding the prevention of HIV and gaps

that exist.
Recommendations for Future Research
To address some of the limitations identified in this review, we
have some
recommendations for future HIV/AIDS prevention
interventions. First,
researchers should test interventions in different regions across
the United
States. Interventions should be tested in more regions across the
United
States even regions with lower incidence rates of HIV, to
maintain low num-
bers (CDC, 2009). In addition, interventions should be
conducted at more
diverse locations, for instance health care settings. Second,
researchers
should strive to include a variety of minority groups in
interventions so that
more individuals are reached (Naranjo &Davis, 2000),
furthermore these
interventions should be sensitive to cultural differences. For
instance, there is
a need for more selected interventions (i.e., interventions for
those considered
to be a high risk for HIV), for instance Hispanics and African
American older
adults, as they are often not the target of HIV interventions, as
evidenced by
this review. To recruit and retain minority participants’
researchers may have
to use different recruitment techniques and present interventions
at a variety
of locations. Third, it may prove beneficial to expand upon the
material
included in the interventions. The inclusion of the differences

between younger
and older adults with HIV/AIDS, symptoms, and treatment may
increase an
older adult’s knowledge and understanding of the disease and
what can be
done to manage the disease. Fourth, peer educators should be
considered in
interventions. A peer educator who has been diagnosed with
HIV or AIDS
could increase the impact of the intervention among the
participants (Agate
et al., 2003). For instance, including a peer educator with HIV
or AIDS may
assist in increasing the participant’s perceived susceptibility,
this should be
empirically examined. Fifth, researchers should use randomized
or controlled
study deigns to better test the efficacy of the intervention.
Using randomized
or controlled study designs reduces the likelihood of having
selection bias and
confounding variables, thereby increasing the ability to
generalize the find-
ings of the study. Sixth, researchers should strive to develop
and test valid and
reliable measures to be used with HIV interventions for older
adults. Using
valid and reliable measures in conjunction with randomized or
controlled
study designs increases the ability to better test the efficacy of
interventions.
Last, prevention interventions should, when possible, include
more follow-
ups for instance, 3- and 6-month follow-ups or longer periods of
time
between the initial posttest and the follow-up (Coon et al.,

2003). Including
follow-ups can increase the researcher’s knowledge regarding
the long-term
effectiveness of the intervention.
Conclusion
In conclusion, updating our current knowledge regarding
interventions and
strategies aimed at preventing future HIV/AIDS infection via
educational
interventions is important in understanding what has already
been done and
what should be done in the future. Only eight studies were
found that spe-
cifically evaluated a universal or indicated intervention among
older adults.
Given the fact that more and more older adults are being
diagnosed with HIV
and AIDS, it is clear that more effective interventions are
needed. As evi-
denced by this review there is an immediate need for more
intervention on
all levels for older adults (i.e., universal, selected, and
indicated). Such inter-
ventions should use randomized or controlled study designs and
use valid
and reliable measures. Furthermore, the interventions should
target more

minority populations. We hope that the information provided
here (i.e., what
has already been done in the field and recommendations for the
future) will
be helpful to researchers and organizations dedicated to
preventing HIV/
AIDS among older adults.
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 received no financial support for the research,
authorship, and/or publica-
tion of this article.
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