Changing Scenario in Older Adults
The US population is aging. Life expectancy has increased dramatically during the past century from 47 years for American born in 1900 to 77 years in 2001 (7). Baby boomers will significantly contribute to this growth, as older Americans hitting the age 65 by 2011, will triple (7, 8). Further, life expectancy in America can be attributed to improved sanitation, medical care and preventive health services during the past three decades.

Older Americans also have unique challenges compared with other cohorts. There has also been an acknowledgement at the federal level, that ethnicity is also a driving factor in the “Call to Action (8).” Addressing health disparities among older adults of different ethnic backgrounds will be an underlying theme for the CDC.

It has also been reported that the average 75 year-old may have three chronic conditions and may use up to five prescription drugs. The number of physicians that specialize in geriatric medicine in the U.S. fell by a third between 1998 and 2004 (18). US medical schools as of late have engaged in a number of strategies to entice medical school graduates into geriatric medicine. According to the American Medical Association (AMA) only 330 doctors this year (2007) have completed geriatric training. There is considerable concern about the number of geriatricians facing retirement during the next five years. As a result, the consequences of the nursing shortage may be replicated in geriatric medicine. Questions remain if the medical community at large has the wherewithal to adequately address the demographic needs of older Americans in the next decade, which may also lead to new challenges in health care delivery.

Adding the complexity of HIV/AIDS, older Americans may be confronted with additional challenges in a potentially fragile health care infrastructure. Subsequently, promoting healthy behaviors among older Americans has been a consistent goal of the Centers for Disease Control “Healthy People 2010 Initiative.” Moreover, HIV/AIDS may be indirectly linked to “Responsible Sexual Behavior” a leading health indicators in Healthy People 2010 (22). Consequently, there is no direct acknowledgment of HIV/AIDS in either CDC report (7, 8) or the Behavioral Risk Factor Surveillance System that assists states survey US adults in a wide range of personal behaviors. Nonetheless, increased attention is warranted concerning older Americans affected by HIV/AIDS. Therefore the purpose of this paper is a call for targeted marketing for older Americans with HIV/AIDS.

Scope of HIV/AIDS in Older Americans
According to the National Institute of Health (NIH) the number of older Americans with Human Immunodeficiency Virus (HIV) or Acquired Immune Deficiency Syndrome (AIDS) is growing. Cumulative estimated number of HIV/AIDS cases in the United States for ages 50-54 was 56,950 (5). Furthermore, the number of newly infected persons 65 years and older has grown considerably in the last ten years (2, 3, 5). Estimates have grown from 1008 in 1996 new infections to 10,000 in 2005. Interestingly enough, many factors may contribute to the increased risk of HIV infection in older people. Several reports indicate that the attitudes and knowledge of older Americans appears be less responsive compared to other age cohorts (5, 12).This may be attributed to the lack of prevention programs geared towards older persons and physician comfort levels with geriatric patients in discussing sexuality (14,19). A study that assessed lower-income adults above the age 60 years old, gauged a full range of sexual behaviors. The sample of 179 men and women concluded that older adults wanted to maintain a sexual relationship. Overall, the majority reported having a sexual experience during the past year the study was conducted in 2005. Survey respondents were also residents of subsidized independent living facilities.

Surprisingly, the body of knowledge with respect to older adult sexuality appears to be limited. “One of out of three sexually active older adults infected with HIV has unprotected sex”, according to Ohio University researchers (20). The connection of erectile-dysfunction drugs to HIV in older adults has not been established. However, inferences can be made of the incidence rates of HIV in adults over 50 in urban settings. Researchers at Ohio University have also confirmed that older adults have engaged in riskier behaviors. Incidentally, researchers have acknowledged that many older adults are not sexually active. However, 13% of study participants were identified as being sexually active and having unprotected sex. Studies should intensify over the next decade regarding sexual behaviors and preferences in older adults. Consider the change in demographics and the “effects” of erectile-dysfunction drugs, particularly in older adults. Studies of this magnitude validate the need for targeted intervention.

Evolution of social marketing
Health communications has accomplished a series of makeovers during the past two decades (17, 21). It has evolved from a one-dimensional reliance on public service announcements (21) to a more sophisticated approach which draws from successful techniques used by commercial marketers, termed "social marketing (17)." Rather than dictating the way that information is to be conveyed from the top-down, public health professionals are learning to listen to the needs and desires of the target audience themselves, and building the program from there. This focus on the "consumer" involves in-depth research and constant re-evaluation of every aspect of the program. In fact, research and evaluation together form the very cornerstone of the social marketing process (17).
Social marketing was "born" as a discipline in the 1970s, when Philip Kotler and Gerald Zaltman realized that the same marketing principles that were being used to sell products to consumers could be used to "sell" ideas, attitudes and behaviors. Kotler and Andreasen define social marketing as "differing from other areas of marketing only with respect to the objectives of the marketer and his or her organization. Social marketing seeks to influence social behaviors not to benefit the marketer, but to benefit the target audience and the general society." This technique has been used extensively in international health programs, especially for contraceptives and oral rehydration therapy (ORT), and is being used with more frequency in the United States for such diverse topics as drug abuse, heart disease and organ donation.

Like commercial marketing, the primary focus is on the consumer--on learning what people want and need rather than trying to persuade them to buy what we happen to be producing (21). Marketing talks to the consumer, not about the product. What is interesting about this concept is how this may translate for older adults. The planning process takes this consumer focus into account by addressing the elements of the "marketing mix." This refers to decisions about the conception of publics, partnership, policy and purse strings. These are often called the "Four Ps" of social marketing. Social marketing combines the principles of marketing (price, product, promotion and place) with a social marketing mix strategy that focuses health related behaviors.

Can the same marketing approach work for a cohort that his been primarily ignored? The answer is yes. For example, as the Social Security and Medicare dominate news coverage, it may be easier for partnerships to be cultivated. This type of climate is perfect for social marketing. In addition, physician education and communication is also paramount. The promotion of health behaviors in other cohorts has been the provider-patient relationship. The provider serves as the primary conduit to the patient and sets goals and timelines for patients. This caveat serves as the foundation in social marketing, especially in cultivating partnerships.
HIV/AIDS cases among individuals over 50 has increased 22% since 1991 (1), which has resulted in a changing scenario and the epidemic has evolved. Older Americans, particularly baby-boomers, do not perceive themselves at risk for HIV transmission and may be less likely to take appropriate measures to prevent HIV infection (1, 3, and 4).

Interestingly enough, many factors may contribute to the increased risk of HIV infection in older people. Several reports indicate that the attitudes and knowledge of older Americans appears be less responsive compared to other age cohorts (CDC).This may be attributed to the lack of prevention programs geared towards older persons and physician comfort levels with geriatric patients in discussing sexuality (11, 14) While it is important to attribute this longevity to the emergence of highly active antiretroviral therapy (HAART), consideration must also be made for the mental well being of this cohort. Hence, meeting the prevention needs of older Americans engenders a unique set of challenges. Advances in psycho-social aspects of HIV/AIDS care, particularly in a cohort(s) that may have been neglected before will raise awareness of this changing scenario.

CDC's Advancing HIV Prevention initiative seeks to draw into services, persons who may not have previously encountered traditional HIV programs. This initiative combined with the efforts of social marketing may raise awareness of this important issue.

References

1. AIDS Action. (2001). Older Americans and HIV/AIDS: AIDS Action Recommendations. Washington, DC.

2. Buchannan, R., Huang, C., & Wang, S. (2002). Patient Care and STDs. AIDS (16):9, 441-455.

3. Centers for Disease Control. (2005). HIV/AIDS Surveillance Report: HIV Infection and AIDS in the Unites States and Dependent Areas, 2005. Retrieved from www.cdc.gov on October 11, 2007.

4. Centers for Disease Control. (2002). Analyses of Nursing Home Residents With HIV and Depression Using the Minimum Data Set. The Body: The Complete HIV/AIDS Resource.

5. Centers for Disease Control. [Online] National Health Interview Survey Current Health Topics. 1995 AIDS Knowledge and Attitudes. Retrieved from www.cdc.gov
On October 11, 2007.

6. Centers for Disease Control. [Online]. The Elderly. National Prevention Information Network. Retrieved from www.cdcnpin.org/scripts/population/elderly
On October 11, 2007.

7. Centers for Disease Control. (2004). The State of Aging and Health in America. Merck Institute of Aging and Health. PP 3-48.

8. Centers for Disease Control. (2007). The State of Aging and Health in America. Merck Company Foundation. (3): PP. 3-46.

9. Centers for Disease Control. [Online]. Older HIV Positive Patients in the Era of Highly Active Antiretrovial Therapy: Change of a Scenario. The Body: The Complete HIV/AIDS Resource. March 11, 2003. Retrieved from www.thebody.com
On October 11, 2007.

10. Fallen, S. (2004). Reaching the reluctant client: designing effective HIV prevention to draw persons into services. International Conference for AIDS. July 11-16; 15 Abstract no.C10363.

11. Gale, J. & Livesley, B. (1974). Attitudes Towards Geriatrics: A Report of the King’s Survey. Age and Aging (3):Vol. 1, 49-53.

12. Jacquescoley, E. (2007). Behavioral Prevention Study Gauges HIV/AIDS and Depression in Older Americans. Unpublished.

13. Khalsa, J., Monjan, A., Portegies, P. & Stoff, D. (2004). HIV/AIDS Aging Introduction. National Institute of Mental Health, Center for Mental Health Research on AIDS, Bethesda, Maryland.

14. National Institute of Health. (1997). AIDS and Aging: Behavioral Sciences Prevention Research. NIH Guide, Volume 21, June 20, 1997. PA#97-069.

15. New York State Department of Health. (2005). New York State HIV/AIDS Surveillance Semiannual Report: For Cases Diagnosed through December 2005. Albany, New York,

16. Tebas, P. (2001). Antiretroviral Chemotherapy: When to Start. Retrieved from www.thebody.com on October 11, 2007. The Body: The Complete HIV/AIDS Resource.

17. Weinreich, N. [Online]. What is Social Marketing. Retrieved from http://www.social-marketing.com/Whatis.html on October 22, 2007.

18. American Medical Association. [Online]. Graduate Medical Education e-letter May 2007. Retrieved from http://www.ama-assn.org/ama/pub/category/17553.html#Old_news on November 1, 2007.

19. Ginsberg, T., Pomerants, S., and Freeley-Kramer, V. (2005). Sexuality in older adults: behaviors and preferences. Age and Ageing 34(5):475-480.

20. ScienceDaily. [Online]. One-third of Sexually Active Older Adults With HIV/AIDS Has Unprotected Sex. Retrieved from http://www.sciencedaily.com/releases/2007/04/070425122157.htm on November 1, 2007. Adapted from materials posted Ohio University.

21. Atkin. C. and Wallack L (1990). Mass Communication and Public Health: Complexities and Conflicts. Newbury Park, California: Sage Publications, 1990.

22. Department of Health and Human Services. [Online]. Healthy People 2010. Retrieved from http://www.healthypeople.gov/LHI/lhiwhat.htOon November 1, 2007.