Attitudes towards sexual health and sex behaviour among older adults with HIV in rural southern Malawi

Adults aged beyond the reproductive years are estimated to contribute 14.3% of adult HIV disease burden in sub-Saharan Africa. Research regarding older adults’ sexual health attitudes and behaviours has typically focused on risk of transmission among HIV-seronegative or sero-unknown individuals. However, the sexual health attitudes and behaviours of seropositive individuals have implications for experiences of HIV after age 49, and onward transmission. This paper answers the research question ‘what are HIV-infected older adults’ attitudes towards sexual health and sexual behaviours?’ Data were produced in rural southern Malawi using repeat in-depth interviews (N=136) with men (N=20) and women (N=23) aged 50-90. A third of respondents had HIV. Interview data were supplemented by data from focus groups with older people with HIV (N=3), key informant interviews (N=19) and observations made over 11 months of fieldwork. Attitudes towards sexual health and sexual behaviours were tied to broader understandings of ageing, the body and illness. Both older age and HIV were understood to diminish an individual’s finite store of vitality, recognised by diminishing ability for farm, house and ‘bed’ work (sex). Work was in turn associated with what it meant to be alive: to be an ‘adult’. The adult identity represented the core identity respondents associated with and aspired to. By limiting ability to work age and HIV threatened respondents’ ‘adult’ identities. In response, they employed a range of narratives that realigned behaviours with the ‘adult’ identity. In these narratives, understandings of sex and the body underpinned an emphasis on either continued sexual vitality and activity or the avoidance of sexual risk-taking