Postmenopausal Women: The Neglected Victims of HIV

By Emily Lipscomb

International Women's Initiative News Writer

The transformation of HIV prevention and treatment represents one of the greatest medical victories of the century, reducing HIV-related morbidity and mortality at an unprecedented rate.[1] However, despite these progressive advancements, the proportion of women contracting HIV during postmenopausal years is rising (a statistic which continues to disproportionately include women of colour and women living in poverty).[2] Social and political discourse has committed a great disservice to the world’s older women, neglecting their particular needs and exposing them to fatal health risks.

The prevalence of HIV is a gendered phenomenon, integrating pervasive gender norms, sex-based stereotypes and female oppression. The 2013 UNAIDS Global Report asserted gender inequality as a predominant force driving the HIV epidemic.[3] Globally, women constitute 52% of those living with HIV, a majority which skews to 57% in sub-Saharan Africa.[4] The intersection of ageism and sexism propels older women to the deepest margins of society, critically undermining their sexual health and increasing their susceptibility to HIV infection.

Why is postmenopausal HIV contraction increasing?

1.    Ageist assumptions

Sexual health frameworks typically neglect the needs of older women. This blind spot is a manifestation of prevalent ageist stereotypes of sexual dysfunction, asexuality, and decreased sexual desire.[5] Contrary to these persistent stereotypes, older women do continue to engage in a variety of sexual activities. The primary mode of HIV transmission within older populations is sexual contact.[6] Excluded from the target audience of sexual health programmes, older women are significantly less likely to use condoms or be aware of safe sex practices.

Furthermore, these prejudices have infiltrated institutional practice. Doctors and other health care professionals rarely ask elderly patients about sexual activity, wrongfully presuming them to be sexually inactive.[7] The failure to test older women for sexually transmitted infections, highlight the potential risks, or provide them with contraception, has resulted in a multitude of health problems which could have been avoided.

2.    Inability to negotiate safe-sex and willingness to take sexual risks

Many older women are unable to discuss safe-sex with long-term partners, fearing the repercussions of such investigation. Such a discussion may falsely be interpreted as an accusation of infidelity, or a covert admission of one’s own misconduct. Further, studies conducted within Uganda and South Africa revealed that women who had endured intimate partner violence were 50% more likely to acquire HIV than women who had not.[8] The threat of violence significantly inhibits women’s ability to negotiate safe sex: defying or challenging a partner may provoke adverse reactions. UNAIDS has insisted that achieving a future rate of zero HIV infections requires a zero tolerance for gender-based violence.[9] Women who have endured intimate partner violence throughout their lifetime are, therefore, inhibited by both the fear of retaliation and the consequences of raising mistrust issues.

Further, the social isolation experienced by many older women results in an inadvertent willingness to take sexual risk. Diminished self-esteem among older women, coupled with reduced success in obtaining sexual partners, contributes to increases in risky behaviour when seeking intimacy or companionship. Moreover, no longer burdened with the worry of potential pregnancy, many older women forego using protection, having previously only used such to prevent conception.[10]

3.    Postmenopausal biological susceptibility

The menopause represents a landmark transition period in the lives of women, unparalleled in the male life course. Unfortunately, the changes which occur to vaginal tissue during the menopause increase the biological predisposition to HIV acquisition, irrespective of frequency of sexual contact.[11] This heightened susceptibility evidences the urgent imperative to ensure sexual health policies are directly targeted towards postmenopausal women.

What are the consequences?

Not only do these factors increase the likelihood of postmenopausal HIV contraction, they also tragically inhibit subsequent treatment and prognoses. Recent research suggests that older persons are much more likely to be diagnosed within the later stages of their disease, causing fatally irreversible damage.[12] In 2014, 40% of Americans aged 55 and older were diagnosed with AIDS at the same time as their HIV diagnosis.[13] Furthermore, only 86% of those diagnosed aged 50-59 survive more than one year, decreasing substantially to 73% within those aged 65 or older.[14] HIV contraction during later periods of the life course brings additional challenges; it significantly exacerbates the pre-existing risk of developing cardiovascular disease, musculoskeletal conditions and certain cancers (predominantly cervical cancer).

Older women are a product of their era; they have internalised the duty to be submissive to their husbands, conceal sexuality, and keep personal matters private. Fearing the consequences of stigma and social isolation, many older women hide or disregard their sexual health needs, increasing their vulnerability to health problems. Both international and national policies must adopt sensitivity towards the circumstances of older women, ensuring that their sexual health treatment parallels that of their younger counterparts.

The rapid progression in HIV prevention and treatment must be celebrated; however, such celebration must be shared with the postmenopausal female population. A spotlight must be cast on the needs of this neglected group, ensuring a turning-point in the rates of their HIV infection, so that it may follow the trend of decline already seen among other population groups. Education and awareness raising (both socially and institutionally) will contribute to the reversal of ageist stereotypes, ensuring recognition of the sexual health needs of older women. Further, efforts to eliminate gender inequality will improve the sexual bargaining power of older women, empowering them to investigate a partner’s history and insist on contraceptive use. Attention must be given to these women as a matter of urgency: such neglect is proving fatal.

References:

  • [1] Nisha Andany, V Logan Kennedy, Muna Aden, Mona Loutfy, ‘Perspectives on menopause and women with HIV’ [2016] International Journal of Women’s Health 8, 1
  • [2] Marcia Neundorfer, Phyllis Braudy Harris, Paula Britton, Delores Lynch, ‘HIV-Risk Factors for Midlife and Older Women’ [2005] Gerontologist 45(5), 617-618
  • [3] UNAIDS, ‘UNAIDS Report on the Global AIDS Epidemic’ [2013] p.78 http://www.unaids.org/sites/default/files/media_asset/UNAIDS_Global_Report_2013_en_1.pdf
  • [4] UNAIDS, ‘UNAIDS Report on the Global AIDS Epidemic’ [2013] p.78 http://www.unaids.org/sites/default/files/media_asset/UNAIDS_Global_Report_2013_en_1.pdf
  • [5] Manjula Lusti-Narasimhan, John Beard, ‘Sexual health in older women’ [2013] Bull World Health Organization 91(9), 707
  • [6] Nisha Andany, V Logan Kennedy, Muna Aden, Mona Loutfy, ‘Perspectives on menopause and women with HIV’ [2016] International Journal of Women’s Health 8, 3
  • [7] https://www.cdc.gov/hiv/group/age/olderamericans/index.html
  • [8] UNAIDS, ‘UNAIDS Report on the Global AIDS Epidemic’ [2013] p.80 http://www.unaids.org/sites/default/files/media_asset/UNAIDS_Global_Report_2013_en_1.pdf
  • [9] UNAIDS, ‘UNAIDS Report on the Global AIDS Epidemic’ [2013] p.82 http://www.unaids.org/sites/default/files/media_asset/UNAIDS_Global_Report_2013_en_1.pdf
  • [10] https://www.cdc.gov/hiv/group/age/olderamericans/index.html
  • [11] Nisha Andany, V Logan Kennedy, Muna Aden, Mona Loutfy, ‘Perspectives on menopause and women with HIV’ [2016] International Journal of Women’s Health 8, 3
  • [12] https://www.cdc.gov/hiv/group/age/olderamericans/index.html
  • [13] https://www.cdc.gov/hiv/group/age/olderamericans/index.html
  • [14] Nisha Andany, V Logan Kennedy, Muna Aden, Mona Loutfy, ‘Perspectives on menopause and women with HIV’ [2016] International Journal of Women’s Health 8, 2