OLD FRIEND PROJECT: AN ECOLOGICAL APPROACH TO HIV/

Old Friend Project: an Ecological approach to HIV/AIDS, STDs, and HBV/HCV infection Reduction and Prevention in Elders Residing in Ouro Verde, Manaus, Amazon, Brazil.

EXECUTIVE SUMMARY Literature Review Health is a state of complete physical, social, and mental well-being and not merely the absence of disease or infirmity. Within the context of health promotion, health has been considered less as an abstract state and more as a means to an end which can be expressed in functional terms as a resource which permits people to lead an individual, socially and economically productive life. Health is a resource for everyday life, not the object of living. It is a positive concept emphasizing social and personal resources as well as physical capabilities (Word Health Organization [WHO], 1998. Pg. 1). Following the World Health Organizations (WHO) definition of Health, when developing any prevention and or educational program we must take into consideration the elder as a whole including family members and their community socioeconomic, cultural, spiritual, and political aspects. Taking a Holistic approach will allow the planner to take account of the implications of their activities in relation to the impact on individual and collective health as well-being. 1. Overview of the Brazilians elders reality related to HIV/AIDS/STD/HBV/HCV

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Gerontology understands that aging does not mean a decline, but a string of life, with its peculiarities and characteristics (Almeida & Loureno, 2007). The rising costs of health and social support systems for an aging population will become unsustainable without proactive steps to create individual and environmental changes that promote successful aging (Marquez, Bustamante, Blissmer, & Prohaska, 2008). Many elders do not have a healthy life style and because their social-economic status, they are at high risk for poor-health outcomes as chronic conditions, high risk for STD infections, and mortality, with this statement being also applicable to the Brazilian elder population (Marquez et al, 2008. Pg. 12). The IBGE 2010 Census reported an HIV/AIDS incidence increase on Brazilians 60 years of age and older from 2000 to 2010, with this incidence expected to increase over the next 20 to 40 years. The life expectancy of those with HIV/AIDS is also expected to increase. Brazilian seniors experience stigmatization towards aging, love, and sexuality. As they age there is an increase in the need of family support in order for them to maintain physiological, cognitive, and emotional health. However, being diagnosed with HIV can increase the social stigma and worsen their overall support system (HP, 2005). 2. Psychosocial aspects of aging Aging is a biological phenomenon, affecting humans in the fullness of their existence. As a person ages, their relationship with the world starts being characterized by the physiological, cognitive, emotional, social, occupational performance, and pragmatic adaptive difficulties influencing psychosociological changes in seniors and their families daily routine. Many seniors tend to assign a more mature tone to old facts, which bring to/affect their lives with new

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characteristics; happy or sad, guilt or worthiness, frustrating or rewarding, satisfactory or tolerable; for all that, the seniors psychic dynamics are lush, rich, and complicated (Ballone, 2000). However, in many cases, there is difficulty in accepting the new objectual changes in the relationship with their personal history (reality), becoming an extremely difficult time for seniors and their families; they are not prepared for the adaptation and changes needed. The major difficulty is the feeling of anxiety that accompanies the process of physical and cognitive decline leading to the loss of the seniors independence, a general feeling of loss, and a deep reflection on their life and expects near-death (Teixeira, 2004). Seniors have individual behavioral and physical histories and that fate brings additional factors towards psychic balance affecting their capacity to adapt to their present existential conditions (Ballone, 2000). Brazilian modern society is becoming grounded in current productivity, profit, and utility of each individual person. Each of us has been reduced to a mere social function with no social space left for the elderly. There is a general understanding that new should be mandatory and better. This bias leads society to understand seniors as a social burden. Where they previously felt worthy and successful, now there is an increasing feeling of existential worthlessness. Thus, even individuals who were relatively balanced emotionally during early life, tend to decompensate with old age (Ballone, 2000), which leaves a profound feeling of loss, leading many to depression, alcoholism, prescription drugs, and even recreational or street drug abuse (CDC, 2008). With many seniors suffering from psychosocial decompensation and fragility, any health promotion and prevention programs targeting this population should perform seniors, family, and local community psychosocial need assessment during program development. Moreover, this action would aim to better assist seniors, families and local community to cope

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with new arriving situations and feelings. It would also help seniors to feel better about them as the effectiveness of the program becomes much higher (Gurchiek, 2007). 3. Stigmas and attitudes towards aging, love, sexuality, and HIV/AIDS Studies have demonstrated the need to increase awareness regarding senior sexuality, representation, and social repercussions with consideration on new aspects related to increased life expectancy as struggles with separation, formation of new bonds, and remarriage. There is a need to change the social perception that elders are people who are taking leave from life when they retire. This attitude often extended to other areas of the elderlys lives, depriving them of various opportunities. There is a poor understanding by society of the changes in sexuality during the aging process due a scarcity of information which leads to a misunderstanding of elders sexuality and creates unnecessary difficulties for the elders and society (Almeida & Loureno, 2007; Vasconcellos et al, 2004). Brazilian seniors during their youth years had no sound sex education or an education based on rigid impoverished morals, with repressive and limiting message towards their natural expression of sexuality. Women were the main victims of this rigidity, with the majority having an even more rigid and repressive education designed to build devoted wives and mothers (Almeida & Loureno, 2007). Vasconcellos et al (2004) interviewed males and females in Brazil and Portugal, and analyzed the data from females separately. They only used only the Brazilian female subjects responses (92%), with the explanation that population statistics shows that as age increases, there are proportionately more women in the general population. They reinforce the idea that the vast majority of seniors typically grew up in a restrictive society, where curiosity about sexuality

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rarely acknowledged with one third of their sample receiving little information about sex before marriage, and almost half of the females receiving no education at all. Their data focused on healthy and socially integrated seniors, demonstrating that inhibition of sexual interest coexists in this population correlated with cultural characteristics and intergenerational differentiation. Another important aspect to take in consideration is the stigma and implications associated with people diagnosed as HIV seropositive, becoming much worse for those developing AIDS. This can be directly associated with imminent death, immoral behavior deserving punishment, and the necessary war to stop the spread of the virus. Moreover, this is well recognized in various areas of public health and is directed towards the victims and their guilty (HP, 2005; Garrido, Paiva, Nascimento, Sousa, & Santos, 2007; CDC. 2008). Misleading factors as existence of taboos surrounding sexuality among seniors, the thought that seniors are not sexually active, and they do not use recreational drugs can be directly responsible for the increase on HIV/AIDS/STD/HBV/HCV cases among seniors. In addiction there are greater resources to access pleasures and services (i.e.: erectile dysfunction medication, penis pumps, penile implants, etc.) allowing seniors to be more sexually active. Despite the existence of a few prevention campaigns directed to this population, in general, elders are less informed about HIV/AIDS infection and how little to protect themselves (HP, 2005; Arajo, Brito, Silva, Gimeniz, Queiroz & Tavares, 2007; CDC.2008). STD infections among Brazilian seniors occur mainly through sexual activity (Vasconcellos et al, 2004). Families and healthcare professionals often see seniors as asexual, and may not ask questions about their sexual habits or even suspect they are infect with a STD. This oversight brings serious consequences regarding prevention, diagnosis, and treatment of the elderly. In Brazil many physicians still misdiagnose or make an incomplete diagnosis when

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seniors present symptoms of dehydration, weakness, anorexia, and fever. Moreover, statistics has shown seniors having a high degree of morbidity and mortality due to HIV/AIDS (HP, 2005; Arajo, Brito, Silva, Gimeniz, Queiroz, & Tavares, 2007; Vasconcellos et al, 2004; CDC. 2008). Pereira & Borges (2010), collected sociodemographic, behavioral, and acquired knowledge related to HIV transmission from 224 elderly participants of the Centro de Convivncia do Idoso (Elderly Social Center) in Anapolis, Goias, BR. Their data demonstrated that 103 elders were having sexually active lives and of those reported: 69% never used condoms; 16.5% always used condoms; 15.5% used condoms occasionally; 82.2% did not use condoms the last time; 16.8% used condoms the last time; 18.4% had relations with prostitutes; 77.7% had only one partner in the last six month; 17.4% used illicit drugs; 29% had blood transfusion. In relation to the forms of transmission (N 244) reported knowing virus was transmitted through: 93.8% contaminated needles and syringes; 95.1% unprotect sexual intercourse; 95.5% blood contact; 75% vertical transmission; 76.8% piercing / tattoo. The data also demonstrated some misconceptions regarding forms of transmission as: 79.9% Mosquito bite: 62.1% sharing soap, towels and toilet seats; 49.1% were admitted to the same hospital unit of someone infected. There is the need for more research about the misinformation diffusion in relation to the aging process, the elders love lives, and their sexuality. Those researches will assist in the development of educational programs which can contribute in the reduction of beliefs and taboos related to this subject full of prejudices (Almeida & Loureno, 2007: Arajo, Brito, Silva, Gimeniz, Queiroz & Tavares, 2007; Vasconcellos et al, 2004). 4. Increased cases of HIV/AIDS, STD/HBV/HCV among elders

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The state of Amazonas has a total population of 2,812,557 where: 222,188 are 50 to 59 years of age, 121,269 are 60 to 69 years of age, 61,255 are 70 to 79 years of age, and 27,701 are 80 years of age and over (IBGE, 2010). The city of Manaus had a population of 1,405,835 in 2000 and increased to 1,832,423 habitants (30.34%) in 2011 (Portal Amazonia, 2011). Much of the increase is due to migration. The HIV/AIDS incidences in Brazil has dropped from 1990 2008, however the HIV incidences occurring to the senior population is increasing, going from 1.2 to 1.7 HIV/AIDS cases per 100,000. In 2008, the State of Amazonas had the second highest rate of AIDS with 26 cases of the disease for every 100,000 habitants (country rate: 18 cases per 100,000), 951 fatal cases of the disease representing 9% of AIDS deaths in Brazil (average: 4 deaths per 100,000). The Sindicato dos Mdicos do Amazonas (Physicians Union of the Amazonas) (2008), reported in their blog that the incidence rate of AIDS among people over 50 years of age doubled between the years of 1996 through 2006. It has risen from 7.5 cases per 100,000 habitants to 15.7. Of this latter group, 37% were women and 63% men. The North region of Brazil remains the second in the ranking of the regions when it comes to high incidences of new HIV cases in the elderly population. The figures show 10 cases per 100,000 inhabitants. From January to September 2008 there were 92 new registered cases in the age range 50 to 59 years of age and of these, 84 recorded in Manaus. The Brazilian Ministry of Health (2010), reported 2,152 new HIV/AIDS cases in Amazonas State from 2007 through 2010 where 548 new cases were reported from January to June 2010. From those cases 1,497 were males and 689 were females, with 182 cases in the range of 50 to 64 years of age, 18 cases in the 65 to 79 years of age, and 3 new cases in the 80 years of age and over.

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5. Importance of Wellbeing and Healthy life styles in Elders Wellbeing describes what is non-instrumentally or ultimately good for a person (Crisp, 2008), and it is directly related to health, describing a state of wellness of the body, mind, and soul. When all of those align the individual is content. There is not one path and many different roads can be taken to arrive there. In conclusion, wellbeing helps a person feel that there is a valid reason for their existence and succor to aspire for more (Wellbeingspot.com, 2010). The National Aboriginal Health Strategy Working Party defines health as: ... not just the physical health well-being of the individual but the social, emotional, and cultural wellbeing of the whole community. This is a whole-of-life view and it also includes the cyclical concept of life-deathlife (WHO, 2004). When working to enhance a persons whole wellbeing, there are seven major areas which must be understood before any assessment of need is done or program developed. Those areas are directly connected and affect each other which are: Physical, Emotional, Occupational, Social, Spiritual, Intellectual, and Environmental wellness. There is a body of evidence highlighting the value of a holistic approach to health promotion in terms of mental and physical health and illness. The natural consequence of such correlations is that promoting positive mental health may be seen as significant in terms of health globally in both physical and mental disorders (WHO, 2004). Davis (2011) reported that generally three quarters of people aged 65 or above are living with one or more long-term chronic condition. Providing meaningful information such as diet, physical activity, socialization, smoking, drug and alcohol consumption, and safe-sex, might

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influence better personal choices which lead to a healthy lifestyle, lowering the risk for a high risk behavior, become seriously ill or dying early. Davis article outlines the evidence base for diet and physical activity among seniors. 5.1 Nutrition Davis (2011) stated that Nutritional health is essential and well documented to maintain and or improve the overall health, independence, and quality of life in older people. An elder daily nutritional requirement is generally the same as the rest of the adult population. However, nutritional needs can become more difficult to meet because of physiological, psychological, and social changes associated with aging that affect food, nutritional intake, and body weight. This means older people are at an increased risk of malnutrition. There is a direct link between nutrition and infection. A well-balanced diet is essential to make up for the loss of energy and nutrients caused by infections and comorbidities associated with aging and the disease process. Moreover, besides good nutrition being essential to achieve and preserve health, it also helps to promote a sense of well-being, strengthening the body, and nurses back to health (WHO, 2002). HIV/AIDS infection can cause fever, diarrhea, weight loss, opportunistic infections, and the use of powerful treatments and medications which may influence eating and nutritional absorption. Any time that the daily nutritional requirement needs are not met, recovery from an illness will take longer. Good nutrition is very important from the time of diagnosis of HIV seropositive and vital to combat full blown AIDS. Nutrition education during the early stages of infection can assist the elder to build up healthy eating habits and on their late stage to maintain the health and quality of life (WHO, 2002).

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The World Health Organization (2002) stated that nutritional care and support promotes well-being, self-esteem, and a positive attitude towards life for people and their families living with HIV/AIDS. A healthy and balanced nutrition should be one of the goals of counselling and care for people of all stages with the HIV infection. An effective program of nutritional care and support will improve the quality of life of people living with HIV/AIDS. 5.2 Physical activity Be able to maintain a daily physical activity can be the difference between independency or being in a wheelchair or bed bound for many elders. Physical activity also reduces healthcare costs in all levels. Low physical activity can occur for a number of reasons, including lower level functioning, fear of falling, disability, and low health literacy in terms of the benefits of physical activity (Davies, 2011). Davies(2011) reported evidence for the benefits of remaining active throughout a persons lifespan which can reduce the risk of falls, as well as strengthen bones and minimize the impact of falls; however the fear of falling being the main barrier to physical activity. Studies done by Chin A Paw, van Uffelen, Riphagen, & van Mechelen, (2008) and Tseng, Chien-Ning, Gau, Bih-Shya, Lou, & Meei-Fang (2011), concluded that older adults with different levels of abilities could improve their functional performance by regular exercise training. Another review found that three trials provided evidence that muscle strengthening and balance retraining programs prescribed on an individual basis at home by a trained healthcare professional are likely to be effective in reducing falls (National Institute for Clinical Excellence, 2004). The importance of remaining active during the later years of life has become more widely accepted and there is now a wealth of physical activity opportunities available specifically for older people as the one from Fit as a Fiddle, funded by the Big Lottery Fund that is a nationwide program in

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the United Kingdom (UK) supporting people of 50 years of age and older with physical activity healthy eating, and psychological wellbeing. The aim of this program is to develop a workforce that will actively support older people to improve their health and wellbeing by 2012. Davis (2010) also reported that the UK has adopted physical activity promotion in mental health initiatives as result of robust evidence supporting the role of physical activity in mental wellbeing. The use of non-medical interventions, or social prescribing, has become a frequently employed technique for promoting mental health and overall wellbeing, especially in marginalized or socially isolated groups such as older people and people with chronic conditions (Davis, 2010). The Brazilian Ministry of Health (2007) define physical activity as any movement made by the skeletal system with energy expenditure, which suggests the adoption of more active habits of everyday life in small changes, opting for performing tasks in the home and workplace and leisure and social activities more active. Also recognizing physical activity as an important tool to gain and or maintain the optimum weight, and maintain health. Those benefits include: prevention of osteoporosis / healthier joints and bones; increase muscle strength; improving the immune system; better functioning body and preservation of the independence of the elderly; favorable correlations with reduced smoking and consumption of alcohol and drugs; improvement of Mental Health with decreased depression and stress relief; increased well-being and self-esteem (Brazilian Ministry of Health [MS], 2007). An article published on the University of California San Francisco - UCSF (2011) website stated, Being HIV positive is no different from being HIV negative when it comes to exercise. Regular exercise is part of a healthy lifestyle. People diagnosed with HIV infection can live long, healthy lives, if they get medical care and take care of their bodies. This includes

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getting regular exercise (University of California San Francisco [UCSF], 2011). UCSF (2011) recommended two types of exercise for a HIV seropositive individual. The first being Resistance training which can help offset muscles loss sometimes caused by the disease and aerobic exercise which can strengthen the lung and heart, build muscles, and burns fat. Klemack (2007) calls attention to the metabolic changes caused by highly active antiretroviral therapy (HAART) as abnormal fat distribution, cholesterol, glucose abnormalities, and conditions associated with HIV/AIDS, and including nausea, vomiting, dry mouth, fatigue, rash, weight loss or gain, peripheral neuropathy, insomnia, depression, and gastrointestinal problems. Klemack reported that exercise demonstrated no significant changes on CD4, significant increase VO2 max changes, lactic acidosis threshold (LAT), and potential to improve body composition in HIV/AIDS associated lipodystrophy, psychological benefits leading to improvement of quality of life (QOL). Klemack also concluded, Existing studies need to be further developed, since several studies exhibited inconsistent or questionable results due to small sample sizes or dropouts (Klemack, 2007). Bopp et all. (2004) accompanied 66 subjects between the ages of 18 and 64 (mean 39 + 8), recruited from a HIV/AIDS hospital based program to determine what relationship existed. This study reported that findings suggested that increased levels of physical activity might have beneficial effects on viral load in HIV-infected individuals. Many other studies and articles support the importance of daily activity for elders and HIV/AIDS seropositive individual (World Confederation for Physical Therapy, 2010; Ciccolo, J. T., Jowers E. M. and Bartholomew, J. B., 2004). 5.3 Domestic accidents

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Falls and their consequences has assumed epidemic dimensions in Brazil with women getting the hardest hit and with does falls not affecting only the elderly but the family as a whole. The Brazilian Ministry of Health (2011) reported: Each year, the Unified Health System (UHS) has increased spending on treatment of

fractures in older people. In 2009, the UHS spent US$ 57.61 million in admissions (through October) and US$ 24.77 million in medicines to treat osteoporosis. In 2006, US$ 49 million and US$ 20 million were spent respectively. To promote the health of the population group the Brazilian Ministry of Health called the state and municipal health departments to conduct joint efforts to reduce rates of hospitalization for femoral fractures in the elderly (MS, 2011); Considering the whole country in 2005 alone, 1,304 deaths were related to femur

fractures, and in 2009 this number rose to 1,478 causes. The main cause for the accidents are linked to problems with vision, hearing, inappropriate use of medications, poor balance, progressive loss of strength in the legs, osteoporosis, among other medical conditions that lead to greater likelihood of an elderly falls; 75% of traumatic injuries that show up in hospitals had occurred at the elderlys home. A

more favorable home environment could improve this picture, since 34% of falls generate some type of fracture and 46% of falls/fractures happen during the night on the way to the bathroom or while in the bathroom. Moreover, physical recovery at this stage of life is more difficult and can lead to lung disease related to joint problems and many other related problems to the lack of physical activities. Social Behavior Model and Theory The CDC (2002) recognize that HIV prevention programs must continue to evolve to meet the challenges that integrate the didactic biomedical progress and findings in pre-exposure,

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post-exposure prophylaxis, microbicides, vaccine development, the effects of antiretroviral therapy, innovations in technology, and other HIV-test findings. New interventions are needed to meet the need of populations at high risk and improve the effectiveness of existing interventions in order to develop effective behavioral health programs and or interventions (CDC 2002). Social Behavior theories demonstrate the application of conditioning towards learning new information and social behaviors. Moreover, contribute tremendously to our understanding of human thought and behavior. Glanz & Bishop (2010) stated that behavior is the most prominent contributor to death and disease with evidences suggesting that effective health promotion program usually require behavior change at many levels. Health promotion intervention based on social behavior science theories can be more effective than interventions developed combining multiple theories. These theories present properties that are more effective. Those strategic planning models provide a structured framework for developing and managing public health interventions and improving them through evaluation. In addition, they contribute to advance research and to test innovative intervention strategies. They reported that in a recent review of 116 theory-based articles published in between 2000 and 2005 in two major health education journals; three most frequently mentioned theories were the transtheoretical model/stages of change (TTM), social cognitive theory (SCT), and health belief model (HBM). However, an individuals behavior is usually a function of the behavior of many individuals on multiple levels, and a broader system approach to understanding both the individual and the populations behavior is critical to achieving health promotion (Emerging theories in health promotion practice and research, Pg. 416).

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When choosing social behavior models and theories, it is very important to take in consideration individual, social, cultural, economic, and political factors contributing to the development, maintenance, and change of health behavior patterns. Ecological System Theory (EST) The EST approach to health behavior has been developed out of several historical trends with the most relevant conceptual traditions being draw from public health and psychology. It can also be applied to understand the roles of behavior in the causation and prevention of lifestyle related chronic diseases by focusing on the nature of peoples transactions with their physical and sociocultural surroundings (Health Behavior and Health Education, 2002). The EST assumption is that behavior is influenced by multiple levels: intrapersonal (microsystem: biological, psychological), interpersonal (mesosystem: social, cultural), social settings (exosystem: organizational, community, physical environment, and (macrosystem: policies, laws, customs and cultural values). The ultimate purpose of the ecological models of health behavior is to inform the development of comprehensive intervention approaches that can systematically target mechanisms of change at several levels of influence. Behavior changes are expected to be maximized when environmental and policy support healthful choices and when individuals are motivated and educated to make those choices (Health Behavior and Health Education, 2008). EST allows for integration of other theories and approaches. Marquez et all. (2008) stated that the purpose of their review was to provide an understanding of successful aging and to provide theoretical intervention approaches to promoting a healthy lifestyle and successful aging. They Identified individuals with nonmodifiable and modifiable risk factors associated with health risk. The non-modifiable factors were assumed as factors not subject to intervention and the samples included demographic

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characteristics (age, gender), socioeconomic factors (income, education level), and most genetic risk factors. The modifiable factors were identified as psychological, behavioral, and environmental factors. Their conclusion was that for many people, lifestyle changes occur in a social context of friends, family members, health professionals, community agents, and social environmental settings that contribute to the behavior change process. Thus, taking a multi-level approach to behavior change in older adults is critical. This includes interdisciplinary work that can involve persons with expertise in physical activity, nutrition, economics, urban planning, political science, and so on. Their conclusion would support an ecological model approach towards program development with elders. Jacobson (2011) used ecological perspective to review the current interventions and propose possible new HIV/AIDS prevention efforts for older adults and stated that focusing on HIV/AIDS prevention from the ecological perspective allows the problem to be attacked at various levels. In addition, the ecological model allows for integration of the various theories and approaches (Edberg, 2007). Intrapersonal interventions using the health belief model (HBM) and the precaution adoption process model (PAPM) may be appropriate for HIV/AIDS prevention in older adults. He also reported that empirical research has shown that educational efforts and physician interventions are desperately needed.

Health Belief Model (HBM) HBM can be used as a complement to the ecological Model in the intrapersonal level. HBM was developed in 1950s by social psychologists Hochbaum, Rosenstock and Kegels at the U.S. Public Health Services. Originally it was developed in response to the failure of a tuberculosis (TB) health screening program. HBM is a psychological model that attempts to

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explain and predict health behaviors. This is done by focusing on the attitudes and beliefs of individuals. The model was first presented with only four key concepts: Perceived Susceptibility, Perceived Severity, Perceived Benefits, and Perceived Barriers. Since then, the HBM has been adapted to explore a variety of long and short-term health behaviors, including smoking, overeating, sexual risk behaviors, and the transmission of HIV/AIDS (University of Twente, 2010; Resource Center for Adolescent Pregnancy Prevention, n.d.). The CDC (2002) reported that HBM have demonstrated to be a successful tool in remapping health cognition and preventions, especially in individuals with diseases such as HIV/AIDS. Behavioral interventions have demonstrated its ability to reduce the risk of HIV/AIDS infection, maintaining programs economical and cost-effective. It can also be used for a wide variety of high-risk populations (CDC, 2002). The HBM proposes that individuals tend to take measures to prevent illness if they believe they are susceptible to health problems (perceived susceptibility); if they believe the state of health will lead to potentially serious consequences (perceived severity); if they believe that a course of action available to them will be beneficial in reducing either their susceptibility or severity of the condition (perceived benefits); if they believe that the anticipated barriers (perceived costs) as duration, accessibility to services and accessibility of medical treatment, if not acting do not overcome the barriers; if they have the desire to meet the treatment and that people should do what is best for good health (motivation); and if variables (modifying factors) of personality, satisfaction of participants and partners, and socio-demographic can change (Rosenstock, 1990). Discussion

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There is not concrete knowledge on seniors sexual behaviors and chain of infection. Some articles propose interventions and methods for senior education, but very few have evaluated the results of these interventions and methods. There are few evaluative researches related to the topic and many more researches are need to understand the epidemiology, seniors perception, how they are affected, and characteristics of interventions that can be effective in preventing seniors from being infected with HIV/AIDS/STD/HBV/HCV. Moreover, there is also a need to document and develop health prevention programs for this at risk population.