Introduction
HIV/AIDS (human immunodeficiency virus/acquired immunodeficiency syndrome) has long been considered a disease of the young, and as a result, older adults are often not considered to be an at-risk group. Accordingly, very little attention has been paid to the issue of HIV/AIDS among the Canadian senior population. This raises great concern as adults aged 50 or older comprised an estimated 12.4 per cent of all prevalent AIDS cases in Canada as of December 2008 (Public Health Agency of Canada, 2010). Additionally, reports of annual HIV testing indicate that prevalent HIV cases among Canadian seniors increased from 10.6 per cent in 1999 to 15.3 per cent in 2008 (Public Health Agency of Canada). The proportion of new cases of HIV among Canadian seniors has also increased. From 1985 to 1998, those aged 50 or older comprised 7.6 per cent of all incident HIV-positive test results (Public Health Agency of Canada). In the United States, a similar trend in HIV incidence has been observed with older adults constituting 16.4 per cent of incident HIV diagnoses in 2008, a slight increase from 2005 (15.0%; Brennan, Emlet, & Eady, Reference Brennan, Emlet and Eady2011). The increase in the number of older adults living with HIV/AIDS in North America can be primarily attributed to (1) improvements in antiretroviral treatments, which have allowed individuals diagnosed in their earlier years to live longer; and (2) newly diagnosed infections after age 50 (Centers for Disease Control and Prevention, 2008a).
Contrary to popular belief, both the desire for sexual activity and sexual activity itself do not cease with increasing age. According to the Global Study of Sexual Attitudes and Behaviours (Pfizer, 2002) conducted among Canadians aged 40 to 80, 76.0 per cent reported engaging in sexual intercourse within the past 12 months (including married and non-married individuals). Moreover, a study of midlife singles found that 48.0 per cent of men and 29.0 per cent of women aged 40 to 69 engaged in sexual intercourse in the previous six months (American Association of Retired Persons, 2003). Within Canada, sexual contact is the primary means of HIV transmission for older adults (Public Health Agency of Canada, 2007a). In 2008, the exposure categories of men having sex with men (MSM) (38.5%) and heterosexual contact (38.0%) accounted for similar rates of prevalent HIV cases among those aged 50 or older (Public Health Agency of Canada, 2010). However, there has been an overall trend of decreased exposure from MSM and an increased exposure through heterosexual contact in this population within the past 20 years (Public Health Agency of Canada, 2010).
Several health benefits are associated with continued sexual activity into older adulthood, including (a) the release of endorphins, (b) a strengthened immune system, (c) relief of physical stress, (d) reinforcement of positive emotions, (e) increased burning of fat, (f) increased longevity, and (g) decreased difficulty with activities of daily living (Health Canada, 2006; National Advisory Council on Aging, 2002; Onder et al., Reference Onder, Penninx, Guralnik, Jones, Fried and Pahor2003; Palmore, Reference Palmore1982). Despite these well-established benefits, a number of factors may place older Canadians at increased risk for sexually transmitted infections (STIs), including HIV. These include (a) engagement in sexual intercourse without condoms and with multiple partners (American Association of Retired Persons, 2003; Centers for Disease Control and Prevention, 2008b); (b) insufficient current knowledge regarding STIs, including HIV/AIDS, and how to accurately assess their own risk for infection (Public Health Agency of Canada, 2003); (c) increasing divorce rates (Statistics Canada, 2006a); (d) increased access to and use of sexual-performance-enhancing drugs (American Association of Retired Persons, 2005; Lindau et al., Reference Lindau, Schumm, Laumann, Levinson, O’Muircheartaigh and Waite2007; Schmid et al., Reference Schmid, Williams, Garcia-Calleja, Miller, Segar and Southworth2009); (e) age-related changes in physiology (e.g., vaginal tissue dryness and frailty) (Gaeta, LaPolla, & Melendez, Reference Gaeta, LaPolla and Melendez1995); and (f) inadequate levels of HIV testing (Public Health Agency of Canada, 2007b).
HIV testing has been available in Canada since 1985 (Public Health Agency of Canada, 2007b). However, lifetime HIV testing for individuals aged 50 or older is low in comparison to rates for the general Canadian population (15.0% for those aged 18 or older) (Public Health Agency of Canada, 2005). Specifically, the percentage of lifetime HIV testing for those individuals aged 55–64 is 7.0 per cent, while the rates of testing for those aged 65 to 74 and 75 years or older are 4 per cent and 2 per cent respectively (Public Health Agency of Canada, 2005). Routine testing has important implications with respect to both HIV diagnosis and treatment. Specifically, improvements in antiretroviral medications have enabled individuals to live longer with HIV/AIDS compared to previous years (Public Health Agency of Canada, 2007a). As well, because 27 per cent of individuals of all ages in Canada are unaware of their HIV infection (Public Health Agency of Canada, 2007b), routine testing can aid in the prevention of HIV transmission to others, especially at a time when many seniors may be starting to enter the dating scene once again.
Canadian snowbirds can generally be described as individuals aged 50 or older who primarily reside in the southern United States, or other southern destinations, for one to six months during the winter season. Research indicates that rates of HIV and sexual-risk behaviour for those aged 50 or older in the United States are highest and increasing in southern Florida (Drummond, Reference Drummond1999; Florida Department of Health, 2010), a location where many Canadian seniors winter. Currently, the risk for HIV among these particular Canadian seniors is not known. This article describes a pilot study that examined the sexual and HIV risk-related behaviour of a sample of Canadian snowbirds, with particular emphasis placed on determining the predictors of HIV testing within this population.
Methods
Sample
The population of interest was Canadian snowbirds who temporarily migrate for an extended period of time to Florida during the winter season. Eligible participants were aged 50 or older, had visited Florida in the past 12 months and stayed for one or more months on their latest trip, lived in Canada for at least six months each year, and were able to read, write, and comprehend English. The minimum age requirement of 50 years was chosen because, currently, literature that examines the sexual behaviour of Canadian seniors as a whole is insufficient (for example, the Canadian Community Health Survey does not ask individuals over the age of 49 questions about their sexual behaviour [Statistics Canada, 2009]). In addition, as a result of early retirement, many Canadians are starting to travel south during the winter months earlier than 65 years of age.
Recruitment
This study was carried out with non-probability, convenience sampling. Canadian snowbirds were recruited in both Florida and Canada, either in person or online. In-person recruitment in Florida occurred in three southeastern counties over a 3-month period (February to April). Participants were recruited through pamphlets and posters (e.g., placed on cars with Canadian license plates, and in stores that Canadians were known to frequent) as well as through direct contact (e.g., approaching seniors on the beach). Based on their preference, participants were invited to complete a face-to-face interview, self-administered paper-and-pencil questionnaire, or an online questionnaire. This choice was provided to determine the preferred modes of completion for a survey with many sensitive questions; in all modes, questions were identical and presented in the same order. For face-to-face interview participants only, prompt cards were used for questions that were of a sensitive nature or had repetitive responses over several questions.
Canadian snowbirds were also recruited in Canada, following their return home from Florida. They were primarily recruited online (e.g., through an online advertorial placed in two Canadian Association of Retired Persons newsletters) over a 4-month period (March to June). In-person Canadian recruitment also included posters, pamphlets, and brochures placed at local older adult recreation centres. All participants in Canada were invited to complete an online questionnaire or telephone interview. The option to complete a face-to-face interview was not provided owing to the breadth of locations from which the study participants were recruited in Canada.
The study received ethics clearance from the Office of Research Ethics at the University of Waterloo, in Waterloo, Ontario, Canada.
Survey Instrument
The survey instrument was developed through the compilation of multiple pre-existing survey questions and scales where possible, and through self-developed questions to address previously understudied areas, primarily social, dating, and sexual behaviour in Canada and Florida. Questions examined (a) socio-demographic and travel characteristics, (b) dating, (c) intimacy and sexual risk behaviour, (d) HIV testing, (e) senior-physician communication, (f) travel health insurance, and (g) health care utilization (see Table 1).
Table 1: Survey instrument questions: Sources
AARP = American Association of Retired Persons. HIV/AIDS = human immunodeficiency virus/acquired immunodeficiency syndrome. PHAC = Public Health Agency of Canada.
Most questions included a Likert-type scale response option (for all other questions, respondents were asked to provide specific information – e.g., number of dating partners in Canada in the past 12 months), and the same response options provided in the pre-existing survey materials were included in the survey instrument where appropriate. Questions regarding the recall of specific information – for example, the frequency of engagement in sexual intercourse – were restricted to a 12-month period to minimize recall bias on behalf of the participant. To address the potential for social desirability bias, the 10-item Marlowe-Crowe Social Desirability Scale Version 2 (M-C2) was also included in the survey instrument (Strahan & Gerbasi, Reference Strahan and Gerbasi1972).
The survey instrument was pilot-tested with a group of six seniors (two males, four females) prior to implementation in the field in order to test the wording of newly created questions for comprehension and effectiveness, the flow of the questions, and to determine the survey completion time; three face-to-face interviews and three paper-and-pencil questionnaires were completed. None of the participants expressed difficulty with comprehension of either previously created or newly created questions. As well, none of the participants who completed a face-to-face interview expressed concern regarding question flow. The only concern that did arise was related to question flow within the paper-and-pencil questionnaire. It was found that several participants requested clarification regarding skip patterns located throughout the questionnaire. To rectify this issue, skip patterns were clarified within the questionnaire and made more visible through modifications to font size and style. During pilot testing, the average time required to complete a face-to-face interview or paper-and-pencil questionnaire was 26 minutes and 22 minutes respectively. As neither method of data collection took longer than 30 minutes to complete, it was not deemed necessary to remove any questions from the survey instrument.
Data Analysis
Multivariate Analysis
The dependent variable for analysis was HIV testing (response options: yes, no, not sure). As the authors were not aware of a conceptual framework that could be used to guide the analyses, an exploratory analysis was conducted in which specific demographic, dating, and sexual behaviour variables were selected for inclusion in multivariate logistic regression modelling – variables that the authors felt could plausibly be predictive of HIV testing (based on available literature: American Association of Retired Persons, 2003; 2005; Bulcroft & Bulcroft, Reference Bulcroft and Bulcroft1991; Centers for Disease Control and Prevention, 2007, 2008b; Cooperman, Arnsten, & Klein, Reference Cooperman, Arnsten and Klein2007; Karlovsky, Lebed, & Mydlo, Reference Karlovsky, Lebed and Mydlo2004; Lindau, Leitsch, Lundberg, & Jerome, Reference Lindau, Leitsch, Lundberg and Jerome2006; Lindau et al., Reference Lindau, Schumm, Laumann, Levinson, O’Muircheartaigh and Waite2007; Lovejoy et al., Reference Lovejoy, Heckman, Sikkema, Hansen, Kochman and Suhr2008; Mack & Bland, Reference Mack and Bland1999; Schmid et al., Reference Schmid, Williams, Garcia-Calleja, Miller, Segar and Southworth2009; Statistics Canada, 2006a; Szerlip, Desalvo, & Szerlip, Reference Szerlip, Desalbo and Szerlip2005; Villarosa, Reference Villarosa2003).
Due to small sample size, missing values on independent variables were recoded, where possible, to prevent loss of participants in multivariate analyses. Missing values were recoded through imputation: the missing value was recoded based on the response given by the majority of respondents with similar characteristics, for the given question (Statistics Canada, 2006b), or through logical deduction (Norman & Streiner, Reference Norman and Streiner1994), where applicable. Participants who did not provide a response to the dependent variable of HIV testing were excluded from the analyses altogether (n = 34).
Bivariate and multivariate logistic regression analyses were performed to assess the factors associated with ever having been tested for HIV. HIV testing was treated as a dichotomous variable at the bivariate and multivariate stages with the response option “not sure” collapsed into “no”. Age was treated as a dichotomous categorical variable (< 65 years of age, ≥ 65 years of age) throughout the analyses. This was done to ensure that younger and older snowbirds were not grouped into a single homogeneous group, thus allowing for differences between age groups to emerge throughout the analysis. For bivariate analyses, t-tests were carried out for independent variables that were continuous, while chi-square tests were carried out for independent variables that were categorical.
Variables significant (at p ≤ .20) at the bivariate level were brought forward for multivariate analyses and then assessed for multicollinearity. Multicollinear variables were dealt with by omitting the least theoretically important variables or through the removal of variables with the greatest amount of missing values (Katz, Reference Katz1999). Following this procedure, the remaining significant variables were brought forward for logistic regression modelling. Backwards elimination was used to determine the most parsimonious model; only variables with a p-value ≤ .10 remained in the final model. As the current study involved exploratory research, and due to small sample size, a p-value of ≤ .10 was chosen to ensure that independent variables that might provide important insight into the predictors of HIV, and that should be explored in a larger-scale study, were not prematurely eliminated from the analysis. Statistical Analysis Software (SAS) version 9.1.3 (SAS Institute, 2004) was used to conduct all analyses.
Factor Analysis
Within the survey instrument, participants were asked to indicate how much they agreed or disagreed with 10 statements regarding sex and sexual intimacy. An exploratory factor analysis was performed for this question to aid in the interpretation of the results, with a varimax rotation applied. This type of analysis was appropriate as this question contained multiple related independent variables regarding sex and sexual intimacy (Katz, Reference Katz1999). Factor analysis aided the interpretation of the results by reducing the large number of sexual-attitude variables into their underlying constructs or factors (Cody & Smith, Reference Cody and Smith2006).
Results
Response Rate
Eligibility questionnaires were distributed to 460 participants. In total, 78 participants were not eligible for study participation while 70 participants were eligible but chose not to participate, resulting in a total sample size of 312 and a response rate of 81.9 per cent. It is noteworthy that not all participants deemed ineligible for study participation were truly ineligible, as several online participants reported being removed from the eligibility questionnaire because of a computer error. As a result, these participants were required to re-enter the study webpage and begin a new eligibility questionnaire, leaving their previous one incomplete.
The main survey instrument was administered to 312 participants. Of these, 13 were subsequently excluded from the analyses as they were missing a large number of responses on their online questionnaires, and they did not respond to any questions relating to the study’s research objectives. This resulted in a total sample size of 299 participants, decreasing the effective response rate to 78.3 per cent. It was not possible to compare the characteristics of completers versus non-completers as the non-completers did not provide sufficient socio-demographic information to permit such a comparison to be made.
For the current analyses, only study participants (including both dating and non-dating individuals) who provided a response to the dependent variable of HIV testing (n = 265) were included.
Socio-demographic and Travel Characteristics
The final sample included 265 individuals, with the majority participating in the study while in Canada (83.8%). Most completed an online questionnaire (86.4%), whereas 10.2 per cent completed a self-administered paper-and-pencil questionnaire, 2.3 per cent participated in a telephone interview, and 1.1 per cent participated in a face-to-face interview. The study population had a mean age of 67 years (SD = 6.3, range = 53 to 92); 53.2 per cent were male. Most participants were married (75.8%), and had been married for a mean of 33 years (SD = 16.2, range = 1 to 75). The majority of participants were from Ontario (80.4%) and stayed in Florida for a mean of 3-and-a-half months (SD = 1.5, range = 1 to 6) on their latest trip (see Table 2).
Table 2: Socio-demographic and travel characteristics of sample
a Percents are calculated of those participants reporting a valid answer; they may not add to 100% due to rounding.
Sexual Attitudes Towards Intimacy
Three factors emerged from the exploratory factor analysis. The first was labelled “sex is a pleasurable experience” and included the variables “I do enjoy sex,” “I would be quite unhappy never having sex again”, and “sex is not only for younger people” (Cronbach’s alpha = 0.8). The second factor was labelled “sex is important in my life” and included the variables “sexual activity/intimacy is important to my overall quality of life”, “sexual activity/intimacy is a critical part of a good relationship”, and “sexual activity is a duty to one’s partner”. Cronbach’s alpha for this factor was .64, just above the cut-off of good reliability (i.e., .65 or greater) (Katz, Reference Katz1999). The third factor that emerged included the variables “sex is a pleasurable and necessary part of a good relationship”, “sex does not become less important to people as they age”, and “there is not too much emphasis on sex in our culture today”. Although participants answered each of these questions similarly, this factor was not retained because, theoretically, the factor could not be encompassed by a single construct. This may have been a result of question wording, as the variable “sex is a pleasurable and necessary part of a good relationship” was double-barrelled in nature. Thus, it was not known what portion of the statement the participant was responding to. As well, Cronbach’s alpha for this factor was low at .56 (Katz, Reference Katz1999), and this value did not increase with the removal of any one of these variables. Each variable was therefore analyzed individually. However, the variable “sex is a pleasurable and necessary part of a good relationship” was not analyzed because, as noted, this was a compound statement. Finally, the variable “people should not have a sexual relationship if they are not married” did not load on any one factor and was also analyzed separately.
Dating and Sexual Intimacy Characteristics
Just under one quarter (20.8%; n = 55) of the sample had dated in the past five years; the majority were unmarried (common-law, widowed, divorced, or never married; 74.5%), while one quarter were married. Of the 55 daters, 47.3 per cent dated in Florida only, 36.7 per cent dated in Canada only, 12.7 per cent dated in both locations, and 3.6 per cent dated only outside of Canada or Florida within the past five years. Over three-quarters of daters in both Canada (79.5%) and Florida (77.8%) engaged in sex with their dating partners in the previous year; 76.1 per cent of Florida daters engaged in sex with a Floridian. Few daters in Canada (13.3%) or Florida (14.3%) used condoms consistently (all of the time or usually) with their dating partners.
Prevalence of HIV Testing
The majority of the sample (73.2%) had never tested for HIV (n = 194), while 17.7 per cent reported having been tested (n = 47). A further 9.1 per cent (n = 24) were not sure whether they had ever been tested for HIV. Thirty participants failed to provide a response to this question, while four participants clearly indicated their refusal to respond; these individuals were excluded from the current analysis.
Predictors of HIV Testing
Tables 3 and 4 report the results of the bivariate HIV-testing analyses. Gender and age were not significantly associated with ever having been tested; however, they were brought forward for multivariate analysis to control for their effects on the dependent variable. Gender was also brought forward because of possible interaction effects with other independent variables. Condom use was significantly associated with having tested for HIV; however, this variable was not brought forward for multivariate analysis as it was only asked of individuals who had dated in the 12 months prior to the survey. Finally, although responses to the questions “have you asked a doctor about your sexual life in the past five years?” and “has a doctor asked you about your sexual life in the past five years?” were not significantly associated with the dependent variable, they were brought forward for multivariate analyses because of the potential for interaction with the “marital status” and “HIV testing” variables.
Table 3: Bivariate analyses to assess variables associated with HIV testing (n = 265, unless otherwise specifieda)
a Sample sizes vary due to missing values and questionnaire skip patterns.
b Including common-law, never-married, widowed, and divorced participants.
c Includes Canadian, Floridian, or other American partners.
d Includes those who responded with “not at all”.
e Where inconsistent use = not at all, rarely or sometimes, and consistent use = all of the time or usually.
Table 4: Bivariate analyses to assess sexual-attitude variables associated with HIV testinga
a Sample sizes vary due to missing values.
b Scores ranged from 1 to 5, where 1 = strongly disagree and 5 = strongly agree. SD = standard deviation.
Several independent variables that were significant at the bivariate level were not selected for inclusion in logistic regression modelling due to multicollinearity issues. After the exclusion of these variables, at the bivariate level, individuals who had been HIV-tested were mostly (a) unmarried, (b) not retired, (c) had dated in the past five years, (d) engaged in sexual intercourse with dates weekly or more often in the past 12 months, (e) had a discussion with a doctor about sexual-risk behaviour since the age of 50, and (f) agreed that sex is important in their lives. Two interaction terms were also included in the modelling: “gender” by “dated in the past five years” and “marital status” by “a doctor asked you about your sexual life in the past five years”.
Final Model
Backwards elimination was used to determine the most parsimonious logistic regression model predicting HIV testing (see Table 5). Overall, participants aged 50 to 64 were twice as likely to test as those aged 65 or older (OR = 2.1), and unmarried participants were five times more likely to test than married participants (OR = 5.0). Additionally, the odds of HIV testing were increased for those who reported talking to their doctor about sexual-risk behaviour (OR = 4.4) and those who reported that sex is important in their lives (OR = 2.5). Finally, a gender-by-dating interaction was also observed, with dating males more likely to test than non-dating males (OR = 2.2). Dating females were not more likely to test (OR = 0.2) than non-dating females, and males who dated were 13.6 times more likely to test than females who dated.
Table 5: Final logistic regression model to predict HIV testing (n = 252)
a p-value reported for Wald chi-square statistic.
Discussion
This research was aimed at describing the dating, sexual, and HIV risk-related behaviour of a sample of Canadian snowbirds who winter in Florida – with particular emphasis placed on identifying the predictors of HIV testing within this population – to begin to understand their patterns of HIV testing and to determine whether Canadian seniors may be at increased risk for HIV/AIDS, similar to that observed among Floridian seniors.
While the current study possesses a number of strengths, including the contribution of knowledge surrounding the dating and sexual behaviour of Canadian seniors, it also has several limitations. First, as questions of a sensitive nature were posed, there was the possibility for item non-response across all methods of data collection, although it was most pertinent to face-to-face interview participants. This was tempered by the use of prompt cards whereby the participant could answer using a lettered category rather than stating a sensitive response directly to the interviewer. Moreover, as participants were provided with multiple methods of data collection, they were able to select the method they felt most comfortable completing. Second, as an interviewer was not available to resolve difficulties with the online questionnaire, there was a greater likelihood for non-response and premature termination as well as inaccurate responses and incomplete questionnaires (de Leeuw, Hox, & Dillman, Reference de Leeuw, Hox and Dillman2008). A third study limitation is that a random sampling method could not be employed because there is no complete listing of all Canadians snowbirds who winter in Florida. As a result, the convenience sample of participants who agreed to participate in this study may not have been representative of the larger Canadian snowbird population in terms of knowledge, attitudes, and behaviour. It is also possible that those who agreed to participate may have been more active and motivated to participate compared to those who chose not to. This may have introduced sample bias to the study (Gordis, Reference Gordis2004). Also, as we only recruited snowbirds who winter in Florida, the results may not be generalizable to Canadians who winter in other southern locations (e.g., other southern states, Mexico, the Caribbean, and beyond). Fourth, as this was a pilot study and due to difficulties in locating Canadian snowbirds, a relatively small sample size was recruited. Therefore, it is possible that some associations may have failed to reach significance due to insufficient power and were therefore missed. Alternatively, it is possible that a small number of responses indicative of risk behaviour may have skewed the results towards significance, where such a finding might not be true within the general Canadian snowbird population. Fifth, during analysis, we might have identified more interaction terms if we had tested more variables; however, as this was an exploratory study and we did not want to complicate interpretation of the results, we focused on the most likely interactions based on available evidence and research team expertise. Additional research may be warranted to uncover additional interactions terms. A sixth study limitation is that we were not aware of a conceptual framework that could be used to guide multivariate analysis; therefore, we conducted an exploratory analysis in which we included specific demographic, dating, and sexual behaviour variables that we felt may plausibly be predictive of HIV testing, based on available literature and research team expertise. Further research may be needed to confirm the importance of the identified predictors, as well as to examine other possible factors. Finally, we recognize that a significant proportion of our sample included married participants in monogamous relationships. Therefore, questions surrounding dating and sexual behaviour with dates in both Canada and Florida would not be applicable. We recognize that the first step in conducting future research in this area is to include a larger sample with a greater number of unmarried Canadian snowbirds, as they appear to be the most likely to date and engage in sexual intercourse with their dating partners. However, this does not mean that married snowbirds should be excluded, as a small proportion of those who reported dating in the past five years were married (25.5%).
Despite these limitations, it was particularly important to conduct this research because literature that examines the sexual behaviour of the Canadian senior population as a whole is insufficient. As society continues to perpetuate the notion that sexual activity is inappropriate or rarely practised at older ages, this segment of the population is often neglected when it comes to the topic of sexuality. For example, the Canadian Community Health Survey, which collects information annually on health status, health determinants, and health care utilization, does not ask sexual behaviour questions of Canadians aged 49 or older (Statistics Canada, 2009). It is important to examine the sexual behaviour of Canadian seniors in order to determine how sexually active they are in their later years of life and whether they are engaging in risky sexual behaviour (e.g., non-use of condoms) that may place them at increased risk for STIs, including HIV.
In the United States, the prevalence of HIV/AIDS among those aged 50 or older is highest in Florida, where they account for 28 per cent of all reported AIDS cases and 19 per cent of reported HIV cases in the state (Florida Department of Health, 2010). This is of particular public health importance in Canada as, during the winter months, Florida is a popular destination for many Canadian snowbirds. However, because seniors are not considered an at-risk group, very little attention has been paid to HIV risk within this population. To date, research that examines whether Canadian snowbirds even socialize with Floridians, let alone date or engage in sexual relationships with these individuals, is non-existent. The current study helps to fill an important knowledge gap surrounding the sexual behaviour of Canadian seniors (including snowbirds), especially at a time when the rates of HIV/AIDS among seniors are on the rise in both Canada and the United States.
Few Canadian seniors have ever tested for HIV. As a result, the true HIV status of the Canadian senior population as a whole is unknown. The Public Health Agency of Canada (2005) has reported that rates of lifetime HIV testing among those aged 65 or older is low compared to the general Canadian population, and tends to decline further with increasing age. Consistent with this literature, only 17.7 per cent of the Canadian snowbirds sampled in the current study had ever tested for HIV, with less than one-quarter of testing snowbirds self-initiating the process.
A number of variables were examined to determine the predictors of having ever HIV-tested within the study sample. Overall, the odds of HIV testing were found to be increased for (a) the unmarried, (b) individuals aged 50 to 64, (c) those who had discussed sexual-risk behaviour (e.g., sex with a new partner) with a physician since age 50, and (d) those who indicated that sex was important in their lives. Further, a gender-by-dating interaction was observed with dating males twice as likely to test than non-dating males, and 14 times more likely to test than females. There may be several reasons why males who date are more likely to test than females who date. First, for older men, sexual dysfunction is a relatively common occurrence. A study by the American Association of Retired Persons (2005) found that 23 per cent of older men reported seeking treatment for a sexual-functioning-related problem from their personal physician within the previous 12 months, compared to only 8 per cent of older women. As these men primarily sought treatment from their physician, they may be more comfortable discussing their sexual health with their physician, including the potential for HIV infection and the benefits of HIV testing. A second reason is that society continues to perpetuate the notion that sexuality is inappropriate or rarely practised at older ages (Hodson & Skeen, Reference Hodson and Skeen1994; Karlen & Moglia, Reference Karlen and Moglia1995; Meston, Reference Meston1997; Walz, Reference Walz2002), especially among women. Females who are promiscuous are often labelled with derogatory terms and their behaviour is considered inappropriate. Having multiple partners does not hold the same negative connotations for males (Barash & Lipton, Reference Barash and Lipton2001; Crawford & Popp, Reference Crawford and Popp2003; Milhausen & Herold, Reference Milhausen and Herold1999). Thus, it is possible that females may not be testing for HIV as readily as males, as they do not want others, including their physician, to know their sexual history.
An additional finding of importance is that standard measures of HIV/STI risk, including sexual-risk behaviour (Neundorfer, Harris, Britton, & Lynch, Reference Neundorfer, Harris, Britton and Lynch2005), were not associated with a person’s ever having tested for HIV. Specifically, testing was unrelated to (a) dating in Florida versus Canada, (b) number of dating or sexual partners, (c) frequency of engagement in sexual intercourse with dates, (d) condom use with dating partners, and (e) STI diagnosis in the past five years. One possible explanation for this finding is that those who are engaging in the riskiest sexual behaviour are not testing for HIV. This trend stresses the need for increased attention and education targeted at the older segment of the population.
A number of measures could be put in place to reduce the occurrence of sexual-risk behaviour among the Canadian senior population. First, talking about sexuality with older adults should not be seen as taboo. It is clear that sexual activity continues to be practised in older age; therefore, physicians need to become more comfortable raising and openly discussing sexuality and sexual risk with their older patients. This is particularly important as only 22 per cent of women and 38 per cent of men reported having discussed sex with their physician since the age of 50 (Lindau et al., Reference Lindau, Schumm, Laumann, Levinson, O’Muircheartaigh and Waite2007), and physicians initiated the conversation with only 17 per cent of their older patients (Pearce, Mairs, Bullock, & Jessup, Reference Pearce, Mairs, Bullock and Jessup2010). Second, there is a noticeable need for research that focuses on the sexual health of older adults, which is exemplified by the Canadian Community Health Survey’s ceasing to ask about sexual health when a person reaches the age of 49 (Statistics Canada, 2009). It is important to examine the sexual behaviour of Canadian seniors to determine their level of sexual activity and whether they may be engaging in sexual behaviour (e.g., non-use of condoms) that may place them at increased risk for HIV or other STIs. A third measure is counselling for older adults regarding their risk for HIV and, in particular, the importance of condom use. As many newly single older adults have not used a condom in years (if at all), it is essential that they are both educated and feel comfortable negotiating the use of a condom with a new partner and physically using them with the partner. Finally, additional research is needed to uncover the motivations for and against HIV testing within the older population segment. This will allow potential barriers to testing to be uncovered and for interventions (e.g., testing programs) to be targeted at seniors, especially those who are at increased risk for STI/HIV infections. Increased testing will help to fill a knowledge gap regarding the true HIV rate of the Canadian senior population.
In terms of future research, examination of alcohol and drug use among the Canadian snowbird population may be warranted. It is not known if or how alcohol and drug use may be associated with the snowbird lifestyle. In particular, additional research should examine whether an association exists between alcohol or drug use and dating or sexual-risk-related behaviour among Canadian snowbirds while in Florida and in Canada, as previous literature has documented this association in younger cohorts (Capaldi, Stoolmiller, Clark, & Owen, Reference Capaldi, Stoolmiller, Clark and Owen2002; Centers for Disease Control and Prevention, 2008b; Rashad & Kaestner, Reference Rashad and Kaestner2004).
Conclusion
This study is thought to be the first to investigate the dating, sexual, and HIV-risk behaviour of Canadian snowbirds who winter in Florida. The results of this small-scale pilot study suggest that Canadian snowbirds are dating and engaging in sexual intercourse frequently with their dating partners, in both Canada and Florida. However, it is also evident that Canadian snowbirds are not routinely protecting themselves against HIV or other STIs. Despite the proportion of older Canadians engaging in risky sexual behaviour with their dating partners, the proportion of these adults ever having been tested for HIV remains low. This study supports the need for further research to better understand the HIV-testing behaviour and sexual interactions of Canadian snowbirds to determine whether, similar to Floridian seniors, they are at increasing risk of contracting HIV.
