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

• Main Authors: Cheryl Johnson (Author), Moses Kumwenda (Author), Jamilah Meghji (Author), Augustine T. Choko (Author), Mackwellings Phiri (Author), Karin Hatzold (Author), Rachel Baggaley (Author), Miriam Taegtmeyer (Author), Fern Terris-Prestholt (Author), Nicola Desmond (Author), Elizabeth L. Corbett (Author)
• Format: Book
• Published: BMC, 2021-04-01T00:00:00Z.
• Subjects: article
• Online Access: Connect to this object online.
• Notes: 10.1186/s12889-021-10573-7; 1471-2458
• Keywords: Life-course theory; Age stratification; Socioemotional selectivity; HIV/AIDS; HIV self-test; Public aspects of medicine; RA1-1270
• Source: BMC Public Health, Vol 21, Iss 1, Pp 1-13 (2021)

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.