The Significance of the Missed Assessment: HIV/AIDS in the Older Adult
Submitted by Carol A. Eliadi, EdD, JD, APRN
Tags: aging aids behavior Community Health Nursing disease elderly hiv risk factors
Sarah L. Jameson, Student Nurse
Carol A. Eliadi EdD, JD, APRN
Assistant Dean and Associate Professor
School of Nursing
Massachusetts College of Pharmacy and Health Sciences
Human Immunodeficiency Virus (HIV) came into the public view in June of 1981 (Goodroad, 2003). Since that time the health care system has faced many struggles related to the understanding the virus itself and in caring for those affected and likely to be affected by this life threatening communicable disease. The initial struggle involved identifying, naming, and determining the vehicle of transmission for the virus. After this information became known, the focus shifted to treatment modalities and preventative education strategies and recommendations.
In all people, regardless of age, HIV and Aquired Immune Deficiency Syndrome (AIDS) affects CD4+ T cells. The role of the CD4+ T cells is to engage other types of T cells to rid the body of invading micro-organisms and viruses. When HIV is contracted, the action of CD4+ T cells is inhibited and the regeneration of CD4+ T cells is slowed.The Human Immunodeficiency Virus utilizes the CD4+ T cells normal replication process to replicate itself. Once the production of unaffected CD4+ T cells cannot keep up with the HIV virus invasion, the number of T cells decreases to two-hundred or less, yielding an AIDS diagnosis. A normal CD4+ T cell count is between six-hundred and twelve hundred. Immunity typically declines with age as part of the normal aging process and as such, places the older adult who is infected with HIV at increased risk for a rapidly declining CD+ T cell count, severe opprtunistic infections, other viral infections, and subsequently, an increased morbidity and mortality. While older adults are certainly at risk for other sexually transmitted diseases as a result of engaging in high risk behaviors as is the general adult population, this paper focuses on the often overlooked risk of HIV in this special population.
Despite a societal belief that older adults are outside of the stereotypical risk population for HIV, the elderly are most certainly at risk for and do contract and transmit the Human Immunodeficiency Virus. As this at risk population is not typical, it often is ignored in terms of education regarding sexually transmitted diseases. This factor compels the healthcare provider caring for this at risk population to be vigilant regarding conversations about sexual practices and teaching to prevent the infection and transmission of HIV in the older adult population. HIV is transmitted through sex and other methods of sharing body fluids such as sharing needles for medications, illicit drugs, and tattoos. HIV can be passed from mother to baby during pregnancy, birth and through breast milk. The most prevalent route of transmission is sexual activity, and most commonly sexual activity between two men.
In the United States there appears to be a problem of perception and stereotypes. When people think of the elderly, they do not think of sex (Mueller, 1997). It is often perceived that people lose their inborn natural sex drive as they age. Contrary to this ageist belief, people continue to have desires and engage in sexual behaviors with increasing age. It is a normal and typically healthy human drive. One study of 3005 older adults found that sexuality is closely linked to the perception of health and the majority of the participants not only have intimate relationships, but regard this expression of sexuality as important to life (Lindau, Schumm, Laumann, Levinson, Muircheartaigh, & Waite, 2007). It was discovered that 73% of participants between the ages of fifty-seven and sixty-four, 53% of those between sixty-five and seventy-four, and some 26% of participants between seventy-five and eighty-five reported being sexually active in the prior year (Lindau et al., 2007). Another study reported that 82% of people over age fifty have had one or more sexual partners in the previous five years (Gott, 2001)
Of course some factors may decrease otherwise active sexual behaviors in the older adult. Medications commonly found to decrease libido include some blood pressure medications, selective serotonin reuptake inhibitors, anti-anxiety medications, and opiod pain medications. Loss of a spouse considerably decreases sexual activity among the older adults as the majority of older adults in sexual relationships are in such a relationship with a spouse (Lindau et al., 2007). Lindau et al. found that 78% of older adult men had a spousal or other intimate relationship while only 40% of women had this type of relationship (2007). Twenty two percent of men interviewed in this same study continued to have a sexual relationship despite no spousal relationship, while this only applied to 4% of women. This may be attributed to longevity of life for women versus men. It may also be related to women reporting less interest in sex in older adulthood (Lindau et al., 2007). Arthritis, depression, anxiety, and other disorders may also cause a decrease in libido in the senior patient. Many of these problems could possibly be addressed by physicians who might change medications or otherwise treat the condition, however less than 40% of men and only 22% of women reported discussing sex with a physician beyond the age of fifty (Lindau et al., 2007).
Considering the number of older adults that believe sexuality relates to good health, physicians and other health care providers may want to consider including discussions about sex and sexual issues with the patient over the age fifty as a component of the routine patient encounter. Gott concluded that although patients and physicians have difficulty initiating discussions about sex and sexuality, an individual’s sexual habits remain unknown unless the older adult is asked specifically about his or her sexual behaviors (2001). Although sexual activity statistically decreases with age, the increasing number of older adults diagnosed with an HIV diagnosis and other sexually transmitted infections calls attention to the need for action on the part of researchers, physicians, nurses, and the older adult as well to mainstream this health problem.
Historically, perceptions of the cohort populations at risk for contracting HIV have been somewhat erroneous. “Originally perceived as a disease exclusive to homosexual men, society has begun to realize that HIV affects society as a whole, including the heterosexual [male] population, women, and children.” (Emlet, 1997, p. 69) HIV and AIDS are also mistakenly perceived to be diseases of young people.
Approximately 10% of Americans over age 50 have at least one risk factor for HIV infection. (Stall & Catania, 1994) Factors that place anyone at increased risk for contracting HIV include: men having sex with other men, blood transfusions before 1985, injection drug use, having a risk-taking sexual partner, and the lack of consistent condom use. These risk factors are directly related to the mode of transmission which includes any activity in which body fluids may be shared between an infected person and an uninfected person. Other risk factors include multiple sexual partners, contracting other sexually transmitted infections, and using substances such as alcohol that may affect inhibition. There are also biological factors that put the older adult at increased risk for contracting HIV. Post menopausal women exhibit normal physical changes that may increase risk of transmission and contraction of HIV. Mainly, thinning of the vaginal wall and a decrease in natural lubrication results in increased susceptibility to vaginal tears and thus provides direct access for HIV to enter the bloodstream (Lieberman, 2000). People often do not consider that the older adult may be having sex with multiple partners, may be having sex with someone of the same sex, may be sharing needles for prescribed medications, or using other illicit drugs and sharing needles, all factors which increase the risk for HIV. (Mueller, 1997) It is difficult to rank these routes of transmission for this population as many infected older adults report that they are unaware how they actuallycontracted the virus. However, men who have sex with men, do comprise the majority of individuals over fifty with HIV (Center for Disease Control and Prevention e, 2007). For all males, transmission category ranks as follows: Men having sex with men (64%), intravenous drug use (16%), heterosexual contact (12%) and a combination of male to male contact and intravenous drug use (7%) (Center for Disease control and Prevention, 2007). For females, high risk heterosexual contact far supercedes any other transmission category at 72% and intravenous drug use at 26% (Center for Disease control and Prevention e, 2007).
The behaviors that increase the risk of contracting or transmitting HIV must be understood by the population in that preventative measures b undertaken. Gott reported that 65% of adults over the age of fifty received very little to no education about HIV and the percentage was similar for other sexually transmitted infections as well (2001). Similar data was collected from primary care physicians in 1997. Skeist and Keiser found that 61% of physicians rarely or never discussed HIV or AIDS with patients over the age of fifty. Nearly 68% of physicians rarely or never discussed reducing risk factors with older patients; and 40% reported rarely or never asking the patients over age fifty about potential risk factors for HIV. These findings were significantly different from discussions these same physicians reported as having with those patients under age the age of thirty. With the younger population, 93% of physicians reported discussing HIV risk behavior at least sometimes with the majority reporting having this important discussion regularly. From the data gathered in the study, the researcher was able to conclude that younger physicians believe older adults do not engage in behavior that can place one at risk for HIV and younger physicians are more uncomfortable discussing sexual behavior and intravenous drug use with the older adult patient (Skeist & Keiser, 1997). This belief is counter-productive for those adults over age fifty. A patient’s history must be considered in order to determine if the individual has ever engaged in behaviors where contracting HIV was a possibility as this virus may have gone unrecognized or undiagnosed for many years prior to a particular health visit. It is clear that primary care physicians must be made aware of the possibility of HIV and associated risk factors presenting in older adults.
The risk behaviors of the elderly are not well documented. One study done nearly 15 years ago by Stall and Catania found that there are elderly who engage in risky sexual behaviors with multiple partners of the same or opposite sex, are less likely than adults in their twenties to take preventative measures such as using condoms consistently, to receive treatment for intravenous drug use, and to refrain from sharing needles. Despite reported risky behaviors in the older adult population, many within this age group have never had a test for HIV (1994). The Center for Disease Control reports that based on a survey in 2007, less than 35% of adults ages forty-five to sixty-four and less than 15% of adults over sixty-five have ever been tested for HIV (Center for Disease Control and Prevention b, 2008). A study done in 1996 by Keitz and others showed that HIV testing outreach had been successful at reaching the population most susceptible to contracting the virus. However, the target population in this study was the younger adult. (Mueller, 1997). This same study recognized that a focus on targeting the young adult may account for some of the reasons that HIV has been diagnosed later and only after the disease has progressed in the older adult patient. This is problematic as HIV is therefore left untreated in the older adult population until the disease has changed to its more life-threatening, more difficult to treat, and more costly counterpart, Acquired Immunodeficiency Syndrome (AIDS). (Mueller, 1997) Outreach targeted toward the younger population almost exclusively, instead of the population as a whole, represents a flawed public health initiative.
Ongoing technological research has served to increase the life expectancy for Americans and more people are living longer and healthier lives. Advances in medicine have also served to increase the life expectancy for those infected with HIV or AIDS. The CDC concluded that 15% of all new diagnosis of HIV and 19% of AIDS diagnoses are related to people over the age of 50. (Center for Disease Control and Prevention a, 2008). Some factors that might contribute to older adults contracting HIV include: (1) Performance drugs such as Viagra and other male enhancement drugs have made it easier for older adults to continue sexual activity (Lieberman, 2000) (2) Internet dating has put divorcees back in the dating scene after many years of marriage and (3) Some older men and women are no longer concerned about pregnancy and in not perceiving themselves at risk, do not use condoms. (Crisologo, Campbell, & Forte, 1996)
The CDC estimated that at the end of 2006, there were 1.1 million people with diagnosed or undiagnosed HIV or AIDS (Center for Disease Control and Prevention c, 2008). HIV infected people over the age of fifty comprise an estimated 280,000 of the individuals (Center for Disease Control and Prevention c and e, 2008). Racial disparaties are more apparent among the over fifty population. There are twelve times as many blacks over the age of fifty infected with HIV as compared to Caucasians (Center for Disease Control and Prevention a, c, and e 2008).
HIV often has very mild symptoms or is asymptomatic until it progresses to AIDS. The symptoms of AIDS in its early stages are fatigue, weight loss, night sweats, and decreased appetite (Altschuler, Katz, & Tynan, 2004). Many older adults may attribute these symptoms to normal changes related to aging that become worse as other illnesses and infections compound them and begin to affect the individual. (Lieberman, 2000 & Older People with AIDS need Compassionate Care, 2005) AIDS related dementia may be falsely diagnosed as Alzheimer’s Dementia. (Altschuler et al., 2004 & Lieberman, 2000).Pnuemocystitis carinii pnuemonia, a characteristic pneumonia found in individuals who are immunocompromised may be misdiagnosed as lung disease. (Emlet, 1997) These misdiagnoses can result in increased morbidity and mortality by preventing the older adult patient from receiving the proper care and resources before the HIV disease is able to progress to AIDS. A new North American study shows that starting antiretroviral treatment earlier could reduce the risk of death by up to 94%. The results of a North American study reports that the risk of death in seropositive patients decreases by 69% to 94% if they start treatment earlier than officially recommended.
This study, which was recently published in the New England Journal of Medicine, could have considerable influence on medical practice. (Health Orbit, 2009).
People over the age of fifty, often have other co-morbidities as well, which can compound their HIV symptoms leading them to feel even more ill and may further contribute to a quickly declining health. Early detection and treatment of HIV should be a priority for all patients, especially those over age fifty.
Stereotyping has likely played a role in the untimely diagnosis of HIV in the older adult. Rochel Lieberman, BS, LCCE, FACCE recognized that physicians are less likely to consider HIV infection, calling it a “missed opportunity to prevent progression of disease.” (2000, p. 177) This research report urged health care providers to provide education to the older adult about HIV risk and prevention and to obtain sexual and drug histories, despite the difficulty in discussing these sensitive topics. (Lieberman, 2000) The importance of this cannot be understated. The older adult is a special population because their normal age related changes predispose them to increased risks. HIV appears to progress more rapidly to AIDS and AIDS to death in this population (Older People with AIDS Need Compassionate Care, 2005) When the older adult is evaluated, the health care provider needs to recognize and take advantage of the unique position he or she is in to have a conversation with the older adult patient and to provide education about risky sexual behaviors as well as other choices that may put the older adult at risk for contracting HIV. Health care providers must be able to educate the older adult about HIV and AIDS and the resources available for those with a positive diagnosis.
It is important for healthcare providers to have knowledge about HIV and current treatment options as well as support and assistance programs that are available to patients with a diagnosis of HIV. This knowledge could prove highly beneficial in lessening the anxiety in those patients who may disclose high risk behaviors and in encouraging the older at risk adult to consider HIV testing. There are an array of public and private assistance programs that are available to HIV infected patients to assist financially with the cost of the medication regimens necessary to improve the quantity and quality of life. It is estimated that the cost for one year of commonly prescribed HIV medications it can be as high as $15,000, possibly equal or close to what the older adult might receive from routine retirement benefits. While the cost of care related to the diagnosis of HIV is significant, the cost of not diagnosing or misdiagnosing is also a serious and likely a more costly concern.
In addition to financial implications of late and or missed diagnosis, it is imperative to remember that this disease is not curable, and at best, becomes a chronic illness over one’s life that has serious implications including pain, depression, and significant life style adjustment requirements.
In order to properly address the risk taking behaviors of the elderly, health care providers caring for this group need to be aware of these behaviors. Many healthcare providers may be reluctant to ask sensitive questions about sexuality due to a fear of embarrassing the patient or of being embarrassed themselves. Perhaps further education is needed on the part of healthcare providers related to how to begin these difficult conversations with their older adult patients and exactly how to ask these sometimes sensitive and intrusive questions. Changing demographics, including the increasing numbers of older adults with HIV or AIDS, warrant that attention be paid to the risk factors of HIV in this population. Not only do older adults need to be aware of the risk as individuals, but healthcare providers need to have awareness of the issue and to incorporate patient teaching on safe sex to the older adults they care for.
Risk behaviors of the older adult can be better documented through research. Research in this area however is much lower than health risk behavior research on the age fifty and younger population. A study by Levy, Kosteas, Slade, and Myers discovered that all research related to irresponsible sexual behavior published in any of the five most widely cited journals excluded people over the age of sixty-five (2006). This same study found that 74% of research related to substance abuse excluded people over age sixty-five. A similar study completed the following year uncovered that approximately 72% of clinical trials related to sexually transmitted disease risk-reduction excluded persons over the age of fifty (Levy, Ding, Lakra, Kosteas, & Niccolai, 2007). Nearly half of the studies had specific exclusion criteria that affected participants over age fifty. Also, no clinical trials related to sexually transmitted disease (STD) risk-reduction were discovered that were specifically limited to participants over the age of fifty. This lack of research may contribute to the minimization of HIV and STD prevention and outreach programs available for older adults. Older adults may be viewed as asexual or safe if there is no data to support that the older adult engages in risky behavior and is also at risk for contracting HIV.
Falvo and Norman (2004) tried to explain the reason for lack of research in the area of sexuality and older adults. They attributed it to “societal norms and beliefs that maintain many people over 50 no longer have any interest or desire to engage in sexual behaviors” (Falvo & Norman, 2004, p. 104) Some researchers, believe that people over age 50 no longer engage in sexual behaviors and purport that research in this area cannot be completed because older people may be reluctant to speak about their private lives, especially as it involves sex. It was also determined from the literature that this population does not perceive themselves to be at risk for contracting HIV making recruiting for research and educational programs difficult (Falvo & Norman, 2004). A brief twenty to thirty minute educational session performed by a nurse at twenty-four centers for older adults included in this study proved that in this brief session, preventative knowledge and perception of risk increased in this population (Rose, 1996)
Existing literature unanimously supports how important it is for the healthcare provider to obtain a sexual history from all patients, including those over the age of fifty. The Association of Nurses in AIDS Care “reccomends that nurses conduct a routine HIV risk assessments on all patients regardless of the presence of any perceived risk.” (Goodroad, 2003) “The taking of sexual histories must be encouraged no matter the age of the patient.” (Lieberman, 2000) Another study reported “ If physicians were willing to endorse and promote HIV/AIDS education in older patients, elders may be more willing to follow reccomendations made by their doctors”(Falvo & Norman, 2004, p. 115)
The CDC reported that “Contributing to the spread of HIV among the over 50 age group and the quick progression of AIDS, is that physicians are often reluctant to discuss sexually transmitted diseasess with older patients.” (Center for Disease Control and Prevention d , 2007, p. 4) The CDC recommends that screening for HIV be performed routinely for all individuals aged thirteen to sixty-four. All individuals regardless of age, requiring treatment for TB should be screened HIV infection. “All patients seeking treatment for STDs, including all patients attending STD clinics, should be screened routinely for HIV during each visit for a new complaint, regardless of whether the patient is known or suspected to have specific behavior risks for HIV infection” (Center for Disease Control and Prevention b, 2008). Health-care providers should test all persons at high risk for HIV annually or before each new sex partner.
A physical assessment text book written by Carolyn Jarvis reccomends a serious of questions be asked of all adult patients relating to their sexual behavior (2004). The conversation need not be difficult. Questions should be matter of fact and communicate acceptance that sexual activity is is acceptable and important (Jarvis, 2004). Introducing the topic may be a relief for many patients. During this history, questions regarding satisfaction, arousal changes, and number of partners may raise the opportunity for further discussion (Jarvis, 2004). Regarding sexually transmitted infections and HIV, Jarvis reccomends the following questions: (1) “Have you had any sexual contact with a partner having a sexually transmitted disease such as gonorrhea, herpes, AIDS, chlamydia, warts, or syphilis?” (2)” When was this contact? Did you get the disease?” (3) “How was it treated? Any complications?” (4) “Do you use condoms to prevent STDs?” (5) Do You have any questions about any of these diseases?” (p. 727-773, 2004). Also important to determine is sexual preference as this relates strongly to HIV risk. (Jarvis, 2004) Specific questions for the older adult should continue to include those relating to sexual activity, satisfaction, and pain (Jarvis, 2004). It may also be appropriate to include questions about multiple partners and infidelity to married older adults as these activities are risk behaviors and choices that need not be judged. Related to the use of drugs, Jarvis also reccomends specific assessment of use of cocain, amphetamines, barbituates, and alcohol and relates high risk sexual behavior to their use. (Jarvis, 2004) It is also necessary, when assessing risk history for all patients, to specifically ask questions about the use of any intravenous substances including narcotics. Another assessment tool that is available for healthcare providers is called the PLISSIT model (Wallace, 2008). This model was written for utilization by healthcare providers when assessing the sexual health of their older adult patients but may also be effective in assessing risk behaviors related to HIV or other STDs. The model acknowledges that privacy is established when beginning a conversation about this topic (Wallace, 2008). It also reinforces that nonjudgemental and respectful attitude is important to show that the provider has an understanding of the older adults’ sexuality. To begin the discussion, the provider first asks for ‘permission’ to have a conversation about sexual health (Wallace, 2008). It may be appropriate to first acknowlege that many patients have difficulties with this aspect of life as they age. Once the provider has permission to begin, open ended questions about the patients concerns or past sexual health questions are appropriate (Wallace, 2008). Also, discovering what the patient knows about risky behavior is very helpful in developing a teaching plan. The topics can be narrowed once the provider has an understanding of the patients educational or therepeutic needs. More objective questions such as number of partners, sexual preference, STD preventative practices, and other potentially risky behaviors are important to discuss before moving on.
‘LI’ is for limited information (Wallace, 2008). This strategy is used when the provider discusses both normal and pathologic age-related changes (Wallace, 2008). In this segment of the tool, the specific risk behaviors that the patient may have been involved with may be further discussed. The provider should be sure the patient knows that he or she may be at risk for HIV or other sexually transmitted infections. ‘SS’ is for specific suggestions (Wallace, 2008). Following education and determining risk, the provider suggests behaviorial changes that may be necessary to reduce risk such as consistant condom and lubricant use, needle disposal or sterilization, and the provider should ask if the patient is willing to be tested for HIV. ‘IT’ is for intensive therapy, the last portion of the model (Wallace, 2008). This is appropriate for those those older adults requiring medication or psychotherapy for sexual problems or dysfunctions (Wallace, 2008). This can also be adapted to include lab work such as HIV testing and later, therapy if warranted.
Some educators and health care providers believe that the older adult may not want to learn about HIVand AIDS. To offset this myth, research was completed regarding the development of an educational program for older adults. Some 250 ethnically diverse adults over the age of fifty were surveyed about their interest in HIV/AIDS education (Altschuler, Katz, & Tynan, 2004). Seventy nine percent of those surveyed believed prevention was a good idea and 48% agreed to attend a group education seminar (Altschuler, Katz, & Tynan, 2004). Most (63%) perferred a same sex group while 22% prefered to learn from their primary care physician (Altschuler, Katz, & Tynan, 2004). Even with their receptiveness to HIV education, more than half reported that they do not know where they can obtain information about HIV and AIDS (Altschuler, Katz, & Tynan, 2004).
The increasing incidence and prevalence of HIV in the older adults needs to serve as a reminder to nurses, healthcare providers, and public health officials that holistic care should be the goal for our population regardless of their age and life style. Information regarding HIV and AIDS is widely available by the media for young people but must be directed at the population as a whole, as this virus affects the population as a whole. For individual healthcare providers, a sexual and social history needs to be obtained and discussed with all patients in a confidential, nonjudgemental and caring manner. A few leading questions could initiate an important discussion that an older person may have wanted to have but did not know how to begin the often difficult and sensitive conversation. If by initiating this coversation and providing a subsequent educational opportunity prevents even one person from getting HIV, it is worthwhile and has contributed not only to the quantity and quality of life for a single patient, but contributed to the health of society as a whole.
- Altschuler, J., Katz, A.D., & Tynan, M. (2004). Developing and implementing an HIV/AIDS educational curriculum for older Adults. The Gerontologist, 44(1), 121-126
- Berman, A., Snyder, S., Kozier, B., Erb, G. (2008). Kozier & Erb’s fundamentals of nursing: Concepts, process, and practice. Upper Saddle River, NJ: Pearson Education Inc.
- Center for Disease Control and Prevention a. (2008, February). HIV/AIDS among persons aged 50 and older. Retrieved November 21, 2008, from http://www.cdc.gov/hiv/topics/over50/resources/factsheets/pdf/over50.pdf
- Center for Disease Control and Prevention b. (2008) Human immunodeficiency virus testing. Early Release of Selected Estimates Based on Data from the 2007 National Health Interview Survey. Retrieved on January 18, 2009, from http://www.cdc.gov/nchs/data/nhis/earlyrelease/200806_10.pdf
- Center for Disease Control and Prevention c. (2008) HIV prevalence estimates---United States 2006. Morbidity and Mortality Weekly Rates. Retrieved on March 1, 2009, from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5739a2.htm
- Center for Disease Control and Prevention d. (2007). Seniors need condoms to prevent spread of HIV among elderly. AIDS Policy & Law , 4.
- Center for Disease Control and Prevention e. (2007). HIV/AIDS Surveillance Report. Retrieved on February 28, 2008, from, http://www.cdc.gov/hiv/topics/surveillance/resources/reports /2007report/pdf/2007SurveillanceReport.pdf
- Crisologo, S., Campbell, M. H., & Forte, J. A. (1996). Social work, AIDS and the elderly: Current knowledge and practice. Journal of Gerontological Social Work , 26 (1/2), 49-70.
- Emlet, C. A. (1997). HIV/AIDS in the Elderly: A Hidden Population. Home Care Provider , 2 (2), 69-75.
- Falvo, N., & Norman, S. (2004). Never too old to learn: The Impact of HIV/AIDS Education Program on Older Adults' Knowledge. Clinical Gerontologist , 27 (1/2), 103-117.
- Goodroad, B. K. (2003). HIV and AIDS in people older than 50: A continuing concern. Journal of Gerontological Nursing , 29 (4), 18-24.
- Gott, C.M. (2001). Sexual activity and risk taking in later life. Health and Social Care in the Community, 9(2), 72-78.
- Health Orbit (April 2009) Treating HIV earlier to decrease the risk of death. Retrieved on April 13, 2009, from http://healthorbit.ca/login1.asp?msg=1&neidws=046041409
- Jarvis, C. (2004) Physical examination and health assessment. St. Louis, MO: Saunders.
- Levy, B., Kosteas, J., Slade, M., & Myers, L. (2006). Exclusion of elderly persons from health-risk behavior clinical trials. Preventative Medicine, 43, 80-85
- Levy, B.R., Ding, L., Lakra, D., Kosteas, J., & Niccolai, L. (2007). Older persons’ exclusion from sexually transmitted disease risk-reduction clinical trials. Sexually Transmitted Disease, 34(8), 541-544
- Lieberman, R. (2000). HIV in older americans: An epidemiologic perpective. Journal of Midwifery & Women's Health , 45 (2), 176-182.
- Lindau, S.T., Schumm, L.P., Laumann, E.O., Levinson, W., Muircheartaigh, C.A., & Waite, L.J. (2007). A Study of sexuality and health among older adults in the United States. New England Journal of Medicine, 357(8), 776-774.
- Manfredi, R. (2002). HIV disease and advanced age: An increasing therapeutic challange. Drugs Aging , 19 (9), 647-669.
- Mauk, K.L. (2006). Reaching and teaching older adults. Nursing2006, 17
- Mueller, M.-R. (1997). Social barriers to recognizing HIV/AIDS in older adults. Journal of Gerontological Nursing , 23 (11), 17-21.
- Older People with AIDS need Compassionate Care. (2005). Senior Care Management , 8 (1), 5-6.
- Rose, M.A., (1996). Effects of an AIDS education program for older adults. Journal of Community Health Nursing, 13(3) 141-148.
- Skiest, D.J. & Keiser, P. (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(May/June), 289-294.
- Wallace, M.A. (2008). Assessment of sexual health in older adults: Using the PLISSIT model to talk about sex. The American Journal of Nursing, 108(7), 53-60.