HIV rates for the over-50s climbing in Europe

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HIV rates are climbing in the over-50s in the UK and across Europe, while the rate of new infections among younger people is dropping, according to new research which warns that the epidemic may be taking a new direction.

The Guardian reports that the study, from the European Centre for Disease Prevention and Control in Sweden, says that older people are most likely to be infected through heterosexual sex. They are also likely to have more advanced disease – which will be harder to treat and could be life-threatening – when it is finally picked up.

The study’s authors suggest that the over-50s may be either complacent or ignorant of the risks of HIV, which has dropped out of the headlines since it became a treatable disease. Their doctors also tend to assume that older people are not running risks through unsafe sex.

“Our findings suggest a new direction in which the HIV epidemic is evolving,” said lead author Dr Lara Tavoschi. “This potentially is a result of older peoples’ low awareness of HIV and how it is transmitted, leading to misconceptions and low perception of their own risk.

“This perception of older people not being at risk is shared by some healthcare providers, and HIV-related services focus more on younger people. Our study shows the need to ensure all ages are appropriately targeted by sexual health services.”

The report says the study has found that one in six new cases of HIV are in people over the age of 50. Between 2004-2015, the rate of diagnosis in older people increased in 16 countries. That included the UK, where the rate of new diagnoses went up from 3.1 per 100,000 to 4.32. Belgium, Germany and Ireland also saw rises in the rate of infection among older people. By 2015, the rate in over-50s was highest in Estonia, Latvia, Malta, and Portugal.

While the rate of newly reported cases remained steady in those aged 15 to 49, it grew by 2.1% each year overall in older people across the 28 European nations, increasing from 2.1 people in every 100,000 in 2004 to 2.5 per 100,000 in 2015. Infection through sex between men increased in both age groups between 2004-2015. Cases due to heterosexual sex reduced in younger people and remained stable in older people, while those attributable to injecting drug use also reduced in younger people but increased in older people.

The report says the National Aids Trust said they had been aware of the rising rates in older people in the UK for some time and that action was needed to prevent these infections, such as targeting different age groups – not just the young – with information about their risks and offering HIV tests in places other than sexual health clinics, such as GP surgeries.

“In recent years there has been a steady increase in HIV diagnoses amongst people over the age of 50 in the UK, accounting for 9% of new diagnoses in 2006 and 17% in 2015,” said Kat Smithson, director of policy and campaigns. “The trend is not limited to, but is more prominent, in the heterosexual population. This presents a challenge to think about whether our prevention efforts meet the needs of changing demographics.”

Government cuts to public health budgets were damaging local authorities’ capacity to offer prevention and testing to older people,” she said. “High prevalence areas are spending a third less on HIV prevention than they were two years ago, and it’s targeted services that are suffering most. We are concerned that generalised health promotion around sexual health and HIV may not reach some smaller but growing areas of need, such as in the older heterosexual population. We have the tools to reverse this trend, but without investment we cannot use them.”

Professor Janet Seeley from the London School of Hygiene and Tropical Medicine, who wrote a commentary on the study, said in the report that many older people did not think they were running a risk. “The main thing is complacency, and also they are in relationships where pregnancy is not a problem, so contraception isn’t something people consider,” she said. “I think there is very little publicity around HIV in Europe now that prevalence and incidence have gone down.”

The new infections were more often caused by heterosexual sex, she thought, because the gay community was far more aware of the risks. “Men of that particular age have gone through quite a lot themselves,” she said. It would be naive to expect governments to do anything about increasing awareness among the over-50s, given the pressures on health services, she acknowledged, but the study should encourage big campaigning groups – in particular the Terrence Higgins Trust, which had been working on the issue. “It is a very difficult group to reach,” she said. “It is very heterogeneous. If someone is going for a well-man or well-woman check up, it could be something the GP could mention.” It is difficult to ask people if they are having unprotected sex in a new relationship, but few people took notice of leaflets because they didn’t think they were relevant to them, she added.

Tavoschi says in the report that HIV services need to be geared up to the needs of this age group. “Our findings illustrate a clear need to provide comprehensive HIV prevention programmes, including education, access to condoms, better testing opportunities, and treatment, targeted towards older adults across Europe,” she said.

“We need to make both healthcare workers and the general population aware of this issue to reduce stigma and inform people about HIV risks and prevention methods. Testing in healthcare settings and innovative HIV test approaches – such as self-testing – need to be more easily accessible to older people to improve early diagnosis and fast-track treatment initiation. When achieved, this should help to prevent further transmission and lower the risk of severe health complications, which is of utmost importance among older adults living with HIV as their risk of mortality is higher as compared to younger individuals.”

Summary
Background: The HIV burden is increasing in older adults in the European Union (EU) and European Economic Area (EEA). We investigated factors associated with HIV diagnosis in older adults in the 31 EU/EEA countries during a 12 year period.
Methods: In this analysis of surveillance data, we compared data from older people (aged ≥50 years) with those from younger people (aged 15–49 years). We extracted new HIV diagnoses reported to the European Surveillance System between Jan 1, 2004, and Dec 31, 2015, and stratified them by age, sex, migration status, transmission route, and CD4 cell count. We defined late diagnosis as CD4 count of less than 350 cells per μL at diagnosis and diagnosis with advanced HIV disease as less than 200 cells per μL. We compared the two age groups with the χ2 test for difference, and used linear regression analysis to assess temporal trends.
Findings: During the study period 54 102 new HIV diagnoses were reported in older adults. The average notification rate of new diagnoses was 2·6 per 100 000 population across the whole 12 year period, which significantly increased over time (annual average change [AAC] 2·1%, 95% CI 1·1–3·1; p=0·0009). Notification rates for new HIV diagnoses in older adults increased significantly in 16 countries in 2004–15, clustering in central and eastern EU/EEA countries. In 2015, compared with younger adults, older individuals were more likely to originate from the reporting country, to have acquired HIV via heterosexual contact, and to present late (p<0·0001 for all comparisons). HIV diagnoses increased significantly over time among older men (AAC 2·2%, 95% CI 1·2–3·3; p=0·0006), women (1·3%, 0·2–2·4; p=0·025), men who have sex with men (5·8%, 4·3–7·5; p<0·0001), and injecting drug users (7·4%, 4·8–10·2; p<0·0001).
Interpretation: Our findings suggest that there is a compelling need to deliver more targeted testing interventions for older adults and the general adult population, such as by increasing awareness among health-care workers and expanding opportunities for provider-initiated and indicator-condition-guided testing programmes.

Authors
Laura Tavoschi, Joana Gomes Dias, Anastasia Pharris and the EU/EAA HIV Surveillance Network

The Guardian report
The Lancet HIV Journal article summary
The Lancet HIV comment


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