'Too old to test?': A life course approach to HIV-related risk and self-testing among midlife-older adults in Malawi

Abstract

Background: Despite the aging HIV epidemic, increasing age can be associated with hesitancy to test. Addressing this gap is a critical policy concern and highlights the urgent need to identify the underlying factors, to improve knowledge of HIV-related risks as well as uptake of HIV testing and prevention services, in midlife-older adults.

Methods: We conducted five focus group discussions and 12 in-depth interviews between April 2013 and November 2016 among rural and urban Malawian midlife-older (≥30 years) men and women. Using a life-course theoretical framework we explored how age is enacted socially and its implications on HIV testing and sexual risk behaviours. We also explore the potential for HIV self-testing (HIVST) to be part of a broader strategy for engaging midlife-older adults in HIV testing, prevention and care. Thematic analysis was used to identify recurrent themes and variations.

Results: Midlife-older adults (30-74 years of age) associated their age with respectability and identified HIV as "a disease of youth" that would not affect them, with age protecting them against infidelity and sexual risk-taking. HIV testing was felt to be stigmatizing, challenging age norms, threatening social status, and implying "lack of wisdom". These norms drove self-testing preferences at home or other locations deemed age and gender appropriate. Awareness of the potential for long-standing undiagnosed HIV to be carried forward from past relationships was minimal, as was understanding of treatment-as-prevention. These norms led to HIV testing being perceived as a threat to status by older adults, contributing to low levels of recent HIV testing compared to younger adults.

Conclusions: Characteristics associated with age-gender norms and social position encourage self-testing but drive poor HIV-risk perception and unacceptability of conventional HIV testing in midlife-older adults. There is an urgent need to provide targeted messages and services more appropriate to midlife-older adults in sub-Saharan Africa. HIVST which has often been highlighted as a tool for reaching young people, may be a valuable tool for engaging midlife-older age groups who may not otherwise test.

Trial registration: ClinicalTrials.gov NCT02718274.

Keywords: Age stratification; HIV self-test; HIV/AIDS; Life-course theory; Socioemotional selectivity.

Fig. 1

Example of perceptions of social positions, HIV-related risk and HIV testing by social age and gender among ‘respectable midlife-older adults in urban and rural Malawi. This figure is illustrative using three examples of age stratification-life course variation by gender among midlife-older adults in urban and rural Malawi: (1) Social positions of older women as custodians of health in the family is related to women’s representation of HIV risk, such as caring for sick relatives and burial rituals which are considered their responsibility and so, represent a ‘respectable’ risk that can be acknowledged openly; (2) Social positions of respect and being leaders in the community relates to midlife-older adults perceptions that testing is inappropriate for their age this HIV risks resulting in the “othering” of HIV-related risk behaviours as those which are contrary to characteristics of midlife-older adults; and (3) Social positions among older women as faithful and trustworthy relates to men’s views that they are low risk, and because of their lack of knowledge about HIV serodiscordancy among couples, they do not think they need HIV testing