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C
URRENT
O
PINION
Sexually transmitted infections in older populations
I. Mary Poynten
a
, Andrew E. Grulich
a
, and David J. Templeton
a,b
Purpose of review
People are living longer and healthier lives. In recent years, there has been a focus on recognition of
ongoing sexual activity among older adults and leading from this, the potential for an increase in
diagnoses of sexually transmitted infections (STIs). Data on STI rates, sexual behaviour and factors
affecting susceptibility to STIs are discussed.
Recent findings
There is limited published literature in this field and few recent longitudinal studies of STI acquisition in
people older than 50 years. Although there is evidence of an increase in incidence, STIs remain rare in
older compared with younger populations. Compared with their heterosexual counterparts, older men
who have sex with men are at higher risk of incident HIV and some other STIs. The HIV epidemic is
ageing as a result of increasing life span and acquisition of HIV at older ages. Improved longevity,
evolving societal norms and physiological changes may place older people at risk of HIV and other STIs.
Summary
Routine STI screening is not warranted in all older people. Education and prevention strategies for all
people at greater risk of HIV, regardless of age are required. Age-appropriate interventions designed to
impart knowledge and provide the requisite skills needed to reduce STI risk in older age would be
beneficial.
Keywords
ageing, HIV, older age, sexual behaviour, sexually transmitted infections
INTRODUCTION
There is no question that sexually transmitted infec-
tions (STIs) are primarily a health issue of young
people, both in terms of incidence and health
sequelae. However, the population globally is age-
ing and rapidly increasing numbers of people are
living long, healthy and potentially sexually
active lives. In recent years, there has been a focus
on the need to recognise sexuality and sexual health
needs as important components of older people’s
lives. Studies of middle aged and older women con-
sistently report that sexual relations are important
to women in these age groups [1,2]. A reluctance by
health professionals and aged care services to
acknowledge these needs has been highlighted
[3,4]. Despite the growing discussion around the
recognition of sexuality and sexual activity in older
age, there is limited research available on rates and
patterns of sexual practices and STIs in this demo-
graphic [5,6]. The published literature is sparse and
heterogeneous, with few longitudinal studies of STIs
among women older than 45 years, in particular.
The WHO generally has reported HIV rates in
adults only up to 49 years of age [7]. Some national
health agencies do not provide stratified STI data
beyond 45 years of age, potentially missing import-
ant variations in STI rates within the last three to
four decades of life [8,9]. Many national STI and
sexuality surveys [10,11] concentrate mainly on
younger populations, with the UK National Surveys
of Sexual Attitudes and Lifestyles only recently
increasing the age cutoff from 44 years [6]. In light
of this, many questions remain. First, it is uncertain
whether STI rates are indeed increasing in older
populations, or increasing diagnoses are simply
due to an expanding denominator. Second, little
is known about whether specific high-risk sub-
groups of older people, such as gay men, experience
higher rates. Third, there have been few studies of
whether sexual risk behaviours in older people have
changed over time. Finally it is not known whether
a
Kirby Institute, University of New South Wales, Sydney and
b
RPA Sexual
Health, Royal Prince Alfred Hospital, Camperdown, NSW 2050,
Australia
Correspondence to Dr Mary Poynten, Kirby Institute, The University of
New South Wales, Sydney, NSW 2052, Australia. Tel: +61 2 93850937;
fax: +61 2 93850920; e-mail: mpoynten@kirby.unsw.edu.au
Curr Opin Infect Dis 2013, 26:80–85
DOI:10.1097/QCO.0b013e32835c2173
www.co-infectiousdiseases.com Volume 26 Number 1 February 2013
REVIEW
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
older people are biologically more or less susceptible
to acquiring STIs than their younger counterparts.
This review examines the available literature on
sexual behaviour and STIs among older populations.
We have defined ‘older’ as including populations of
people 45 years of age or older. As there is variability
in the lower age cutoffs between studies, the lower
limit of age for each study is reported. New diag-
noses of STIs rather than chronic or persisting
infection (for instance HIV or syphilis acquired at
a younger age) are examined.
OVERVIEW OF RATES OF SEXUALLY
TRANSMITTED INFECTIONS OTHER THAN
HIV BY AGE GROUPS
Surveillance data from the United Kingdom on STI
diagnoses in genitourinary medicine (GUM) clinics
and community settings from 2008 to 2010 [9]
report specific STI rates in older populations by
sex, only as ‘45þ’. There was virtually no change
in rates of STIs in people older than 45 years from
2008 to 2010. In this age group, chlamydia rates
were 170-fold higher and gonorrhoea rates 24-fold
higher in the 20–24 age group. Despite these huge
differences in rates, it is important to note that there
were more than 5000 new diagnoses of chlamydia
and gonorrhoea in 2010 in this age group. For males,
rates of newly diagnosed syphilis were much more
similar with rates approximately three-fold higher
in young men. However in women, rates in the
young were 20 times more common than in those
aged 45 years or older. There was an increase in rates
of first episode of ano-genital warts from 2002 to
2010 in both sexes in those aged 45–64 and among
those aged 65 years and older. As with the bacterial
STIs, the disease burden was much lower than in
younger age groups, with the highest rates in
the older age groups being among men aged 45 –
64 years (45.5 per 100 000) [9]. Rates in 20–24 year
old men were about 17 times higher. Earlier studies
in the United Kingdom of GUM attendees aged
greater than 45 years reported the rate of STIs more
than doubling in 2003 compared with 1996, the
biggest increase being seen in the 55–59 years age
group. However, this group comprised only 4% of all
GUM attendees [5]. It is plausible that increased
testing and improved sensitivity of diagnostic tests
may have led to the increase in notifications, but the
potential contribution of an increase in riskier
sexual practices among this age group cannot be
ruled out. In a small study at two London GUM
clinics, attendance of women aged 46 years and
over quadrupled from 1998 to 2008, however the
proportion of acute STIs in this age group remained
stable over time [12
&
].
Other countries, such as the United States,
Canada and Australia, have seen a similar increase
in STI diagnoses in men and women over the past
decade. In Australia, among women for instance,
the rate of chlamydia has more than tripled. This
increase has been reported across all age groups,
including those older than 50 years. In 2011, the
rates of chlamydia in women older than 65 years
were 1.5 per 100 000, compared with 2181 per
100 000 in women aged 20–24 years [13]. The over-
all numbers of new diagnoses in men and women
aged 50–59 years and aged 60 years and older,
though still low, increased from 2006 to 2010 for
gonorrhoea, chlamydia and syphilis (men only)
[14]. In the United States, an increase in STI diag-
noses from 2006 to 2010 saw the chlamydia rate
in men increase by 36.4%, compared with a 19.5%
increase in women during this period. Rates of
new diagnoses of chlamydia have remained fairly
constant in those aged 55 – 64 years and those
65 years and older (9.3 per 100 000 and 2.1 per
100 000 in women, 10.9 per 100 000 and 2.8 per
100 000 in men, respectively, in 2010). In contrast,
the rate of chlamydia was over 3400 per 100 000
women aged 20 –24 years in 2010. Similar trends and
differences between age groups were reported for
gonorrhoea. For men aged between 55 and 64 years,
rates of newly diagnosed syphilis were more similar
with rates approximately eight-fold higher in young
men. However in women, rates in the young were
22 times more common than in those aged 55 –
64 [15]. In a cross-sectional cohort study of 541
HIV-infected people conducted in the United States
in 2008, overall STI prevalence was 3% among
people older than 50, compared with 11% in those
aged 18–35 years, demonstrating that STIs continue
to be identified at all age groups [16]. In Canada,
data from British Columbia were collated in slightly
younger age groups of 40–59 years and 60 years or
older. Thus, the reported rates are slightly higher.
KEY POINTS
STIs in older people remain uncommon, but incidence
rates are increasing.
Older people remain sexually active. Negotiating safe
sex may be unfamiliar and challenging, due to lack of
sexual health knowledge and inability to communicate
with healthcare providers about sexual issues.
The HIV-infected population is ageing, due to both
increasing life span and to acquisition of HIV at
older ages.
Some older sub-populations are at particular risk of
STIs, including older gay men.
Sexually transmitted infections in older populations Poynten et al.
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Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
For instance, chlamydia rates in women aged 40 –
59 were 68.2 per 100 000. This was still dramatically
less than in younger age groups [17].
A cross-sectional health insurance clinic-based
study in South Korea, conducted in 2009, enrolled
1804 men and women aged over 60 years. There was
a very low prevalence of syphilis (4 cases, 0.2%),
chlamydia (14 cases, 0.8%) and gonorrhoea (0 cases)
[18]. In China, a cross-sectional study of 11 461 STI
clinic patients from eight cities in Guangxi Province
included 944 individuals 50 years and older. Syphilis
infection was present in 12.7% of this age group
[19]. Notably, there is a lack of detailed epidemio-
logical data from the African and Pacific regions on
STI diagnosis rates in older populations, other than
HIV [20].
Trichomonas vaginalis is one of the most
prevalent STIs worldwide and may be the exception
to the rule of younger individuals being most at risk
of curable STIs. Until recently, relatively little
was known about T. vaginalis risk factors due to
its commonly asymptomatic nature and lack of
sufficiently sensitive and specific diagnostic tests,
particularly for men. Using T. vaginalis nucleic acid
amplification tests, a recent US study found it to be
the predominant STI in women over the age of
20 years, in contrast with Chlamydia trachomatis,
which was more prevalent in younger women
[21]. The mean age of women infected with
T. vaginalis (30.6 years) was significantly higher
than those infected with C. trachomatis (22.3 years)
and Neisseria gonorrhoeae (21.6 years). The same US
research group also reported a similar age-related
prevalence of T. vaginalis among men. The average
age (39.9 years) of T. vaginalis-infected men was
almost a decade older than in infected women,
and, again, infected men were significantly older
than those with C. trachomatis or N. gonorrhoeae
(27.6 and 25.9 years, respectively) [22]. The
reasons for these significant age differences between
T. vaginalis and other curable STIs are unclear.
In men, it may be partly due to age-specific sexual
partnerships with older infected women, among
whom long duration of infectiousness [23] and
changes in reproductive hormone levels [24] have
been suggested to contribute to higher T. vaginalis
prevalence.
DIAGNOSIS OF HIV IN OLDER AGE
Of all STIs, most published literature is available
on HIV diagnoses in older age. In 2005, there were
2.8 million adults aged 50 years and older living
with HIV [25]. It is estimated that by 2015, 50%
of the US HIV-infected population will be aged
over 50 years. The average age of HIV-infected
populations in developing countries can also be
expected to increase, with roll out of antiretroviral
therapy (ART) [26]. This clearly is due to ageing
of the already HIV-infected population. However,
there is growing evidence that the rate of new
HIV diagnoses in people older than 50 years is not
insubstantial, both in developed and developing
settings [27,28
&
,29,30]. For instance, in 2010, people
over 50 years accounted for 14% of new HIV diag-
noses in the United States [31]. Importantly, HIV
diagnosis often occurs later in older people, as seen
in 2010 in the United Kingdom, where late diagnosis
among older adults (aged 50 years and over)
was significantly more common than in younger
adults (62 vs. 48%, P<0.0001) [32]. This is of
concern as delayed HIV diagnosis is associated with
an increased risk of both AIDS and death [32], and
increasing age is also an independent predictor of
AIDS/death among HIV-infected individuals [33].
Frustration has been voiced at the lack of acknow-
ledgement and engagement by world authorities
such as the United Nations with the increasing
challenge of HIV and ageing [26]. Other professional
geriatric and HIV-medicine groups, however, have
collaborated to create guidelines for prevention and
detection of HIV in older adults [34
&&
], and the
Office of AIDS Research of the National Institutes
of Health has commissioned a working group to
develop an outline of the current state of knowledge
and areas of critical need for research in HIV and
ageing [35].
HIV awareness, attitudes, behaviour and testing
were assessed in eight countries in sub-Saharan
Africa from 2005 to 2007. Among 722 adults aged
50 years and older, HIV knowledge was significantly
lower than for younger adults. Older adults were
half as likely to be ever tested for HIV. These factors
have the potential to greatly impact on HIV trans-
mission among older, sexually active adults [36
&
].
HIV risk in older populations was measured in a
large longitudinal study in Malawi, with question-
naires and HIV testing undertaken between 2004
and 2008. The authors found that although HIV
prevalence declined at older ages, the likelihood
of HIV infection remained considerable over age
50 years. This older population contributed 43.5%
and 16.3% of the male and female HIV disease
burden in this sample. However, HIV incidence
was not measured [28
&
].
A study of 8846 people aged 16 and older
conducted in rural South Africa from 2004 to
2009 examined the impact of age at initiation of
ART on mortality. After adjusting for baseline
characteristics, the overall mortality risk was 32%
higher for those who initiated ART at 50 years
or older compared with those initiating at age
Sexually transmitted diseases and urinary tract infections
82 www.co-infectiousdiseases.com Volume 26 Number 1 February 2013
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
25–49 years. Interestingly, this difference was
only apparent in the first year of ART [37
&&
].
Mathematical modelling revealed sobering predic-
tions on the impact of the current ART roll-out on
age-specific and sex-specific HIV prevalence in
South Africa up to 2040. They predicted that while
HIV prevalence in the 15–49 years group would
more than halve, HIV prevalence in the population
aged 50 years and older may nearly double in the
same period. Thus, increased prevention efforts
need to be concentrated on older people in Africa
[38].
A considerable proportion of MSM continue to
be sexually active into their later years and the
sexual repertoire of these older MSM may include
higher risk sexual behaviours that place them at an
elevated risk of STIs [39]. In the United Kingdom in
2010, 13% of newly HIV diagnosed MSM were older
than 50 years, whereas less than 5% of newly diag-
nosed heterosexuals were aged over 50 years. It was
reported that as MSM age, they are less likely to be
tested for HIV [32]. In the United Kingdom in 2011,
large increases in STI diagnoses were seen in MSM,
with between 15 and 20% of STI diagnoses occurring
in men aged 45 years and older. The ongoing
epidemic of lymphogranuloma venereum (LGV)
in the United Kingdom [40], Canada [41] and the
Czech Republic [42], among other countries, is
primarily in older, HIV-positive MSM over 40 years,
which contrasts with the much younger peak age
affected by other bacterial STIs [43].
SEXUAL BEHAVIOURS IN OLDER
POPULATIONS
Certain circumstances that increase higher risk
sexual behaviours and potential STI acquisition
in older populations have been proposed in the
research literature. These include increased numbers
of new partners due to longer life; better health and
higher rates of divorce; lack of awareness of sexuality
and sexual activity by healthcare professionals with
a consequent lack of communication about sexual
health and HIV risk; omission from STI prevention
and health promotion programs; decreased condom
use and lower rates of STI testing; the introduction
and extensive uptake of erectile dysfunction medi-
cations for sexual functioning, and the increase and
ease of foreign travel to countries with easy to access
sex industries [20,30,44
&
,45
&
,46].
A number of recent studies have assessed sexual
behaviour among older populations. In a study in
sub-Saharan Africa [47], men aged 50 years or older
were more likely to have had two or more sexual
partners in the past 12 months than those aged 15 –
49 in four of seven countries. In Malawi, almost half
(n¼192) of women aged 50–64 years and a quarter
aged 65 and older (n¼68) reported recent sex. The
majority of men aged 50–64 years and aged 65 years
and older reported recent sex (84% and 75%,
respectively) [28
&
]. Very high rates of commercial
sex worker contact (46%) among men aged 50 years
and older were reported in a cross-sectional study in
China, with 24% reporting multiple sexual partners
and less than 4% reporting condom use [19].
A subgroup analysis of 120 older women aged
46 years and older attending a UK GUM clinic
showed that most (70%) had been recently sexually
active and more than half (59%) did not use con-
doms [12
&
]. In the South Korean study of people
aged 60 years and older discussed above, though
the response rate was poor (14%), of those who
completed a sexual behaviour questionnaire, 26%
did not use condoms and 10.6% of men reported
contact with commercial sex workers in the past
year [18].
Bateson et al. [45
&
] postulated that internet
dating may place older women at risk of acquiring
STIs, as negotiating safe sex with new partners may
be unfamiliar and challenging in later life. They
surveyed 1788 Australian women using an internet
dating service and found that while women aged
40 years or over were more likely to discuss STIs with
a new partner, they were less likely to refuse sex
without a condom compared with women younger
than 40 years. The relationship between oral erectile
dysfunction medication (OEM) use and STI acqui-
sition was explored in a US study based on pharmacy
and medical claims from 1997 to 2006 for 1 410 806
men aged over 40 years. STI diagnoses before OEM
prescription were higher in men who were pre-
scribed OEM in the subsequent year. After OEM
prescription, they continued to have higher rates
of STIs than nonusers, but they did not experience
an increase in STI rates in the year after OEM
prescription. This strongly suggests that the associ-
ation between OEM use and STI acquisition is
related to individual characteristics of the person
seeking OEM, and is not caused by the use of OEM
themselves [48].
BIOLOGICAL SUSCEPTIBILITY TO
SEXUALLY TRANSMITTED INFECTIONS IN
OLDER POPULATIONS
It is possible that older individuals have different
susceptibility to STIs than their younger counter-
parts. Physiological changes can affect the sexual
responses of men and women and may inhibit or
enhance sexual function as people age. In women,
lower oestrogen levels from peri-menopause
onwards may lead to decreased vaginal secretions
Sexually transmitted infections in older populations Poynten et al.
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Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
during sex [1]. The resultant vaginal dryness and
thinning may facilitate transmission of STIs due to
microabrasions as a result of sexual intercourse
[19,49]. Humoral and cellular immunity, T-cell
activity and immunoglobulin production may be
impaired in older age and STIs can mimic meno-
pausal symptoms, with chlamydia and gonorrhoea
potentially presenting as pelvic pain, deep dyspareu-
nia and postcoital bleeding [49].
CONCLUSION
In many settings, there has been a recent increase in
STI incidence rates in older age, which parallels
increases observed in all age groups. Compared with
younger people, STIs remain rare and routine STI
screening is not warranted in all older people. In
contrast, in both developing and developed settings
HIV is becoming increasingly common in older
people. Emphasis needs to be placed on education
and prevention strategies for all people at greater
risk of HIV, regardless of age. Improved longevity,
evolving societal norms and physiological changes
may place older people at risk of HIV and other STIs.
This necessitates the correction of healthcare
provider assumptions of sexuality and sexual
health in older populations and the development
of age appropriate interventions designed to impart
knowledge and provide the requisite skills needed to
reduce STI risk in older age.
Acknowledgements
I.M.P. (#1016307) and D.J.T. (#1013353) are
supported by Postdoctoral Training Fellowships from
the National Health and Medical Research Council.
The Kirby Institute is affiliated with the Faculty of
Medicine, University of New South Wales and is funded
by the Australian Government Department of Health
and Ageing. The views expressed in this publication do
not necessarily represent the position of the Australian
Government.
Conflicts of interest
There are no conflicts of interest.
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