**Country-level data available**
Over the past 12 years in Europe, there has been a steady increase in the rate of new cases of HIV in older people, indicating a need to increase awareness and tailor testing programmes to the older generation, according to a European Centre for Disease Prevention and Control (ECDC) study published in The Lancet HIV journal. The study found that in 2015, around one in six (17%) of new cases of HIV diagnosed in Europe are among people aged over 50.
The study found that older people (people aged 50 or older) were more likely than younger people (aged 15-49 years) to be diagnosed with advanced HIV disease, and acquire HIV through heterosexual sexual contact.
Between 2004-2015, the rate of diagnosis in older people increased in 16 countries, including in Belgium (3.9% annual average increase - increasing from 2.61 new cases per 100000 older people in 2004, to 4.15 in 2015), Germany (8.1%, from 0.72 new cases per 100000 to 1.83), Ireland (5.4%, from 1.41 new cases per 100000 to 3.33), and the UK (3.6%, increasing from 3.1 new cases per 100000 to 4.32) . By 2015, rates were highest in Estonia, Latvia, Malta, and Portugal (7.50, 7.17, 7,15 and 6.0 new cases per 100000 older people, respectively).
"Our findings illustrate a clear need to provide comprehensive HIV prevention programmes, including education, access to condoms, better testing opportunities, and treatment, targeted towards older adults across Europe," says lead author Dr Lara Tavoschi, European Centre for Disease Prevention and Control, Sweden. "We need to make both healthcare workers and the general population aware of this issue to reduce stigma and inform people about HIV risks and prevention methods. Testing in healthcare settings and innovative HIV test approaches - such as self-testing - need to be more easily accessible to older people to improve early diagnosis and fast-track treatment initiation. When achieved, this should help to prevent further transmission and lower the risk of severe health complications, which is of utmost importance among older adults living with HIV as their risk of mortality is higher as compared to younger individuals." 
In Europe, almost half (47%) of all newly reported HIV diagnoses are made at a late stage of infection for people of all ages. 
The study includes all new cases of HIV in the European Economic Area (the 28 countries of the European Union, and Iceland, Liechtenstein, and Norway) between 2004-2015. During this time, 54102 people over the age of 50 (equivalent to 2.6 people in every 100000) were diagnosed with HIV, compared to 312501 cases in people aged 15-49 years (11.4 in every 100000 people).
While the rate of newly reported cases remained steady in younger people, it increased by 2.1% each year overall in older people, increasing from 2.1 people in every 100000 in 2004, to 2.5 per 100000 in 2015. As a result of these increases, in 2015, 5076 out of the 29419 new cases of HIV in Europe (17.3%) were diagnosed in people over the age of 50.
The mode of infection varied for older and younger people over time, with infection through sex between men increasing in both age groups between 2004-2015, while cases due to heterosexual sex reduced in younger people and remained stable in older people. Cases attributable to injecting drug use also reduced in younger people but increased in older people.
The study showed that among younger people, rates of HIV infection decreased significantly in six countries (Austria, France, the Netherlands, Norway, Portugal and the UK), and increased significantly in 12 countries (Bulgaria, Croatia, Czech Republic, Germany, Greece, Hungary, Latvia, Lithuania, Malta, Poland, Romania, and Slovakia) between 2004 and 2015. For older adults, rates of HIV infection decreased in one country (Portugal), but increased in 16 others (Belgium, Bulgaria, Czech Republic, Estonia, Germany, Greece, Hungary, Ireland, Latvia, Lithuania, Malta, Norway, Poland, Romania, Slovakia, and the UK) between 2004 and 2015.
Data on white blood cell counts were available for 61.5% of people diagnosed in 2015 (18103 of 29419 cases), and the analysis suggests that a higher proportion of older people were diagnosed late, with lower white blood cell counts (39.3% diagnosed with a count below 350 CD4 cells per μl blood, compared with 26.7% of younger people). While this may also be caused by CD4 cell counts falling more rapidly in infected older people than in younger people, it is of concern as this further increases older people's higher mortality risks.
"Our findings suggest a new direction in which the HIV epidemic is evolving. This potentially is a result of older peoples' low awareness of HIV and how it is transmitted, leading to misconceptions and low perception of their own risk. This perception of older people not being at risk is shared by some healthcare providers, and HIV-related services focus more on younger people. Our study shows the need to ensure all ages are appropriately targeted by sexual health services." says Dr Tavoschi.
The authors note that delays in some countries' reporting may mean that not all cases were included in the 2015 figures. As a result, these figures are likely to increase slightly in future years. For this reason, increasing trends are likely underestimated and decreasing ones may be overestimated.
Writing in a linked Comment, Professor Janet Seeley, London School of Hygiene & Tropical Medicine, UK, says: "HIV infection has implications for the long-term health and wellbeing of older people, particularly if they present with advanced infection. In Europe, the USA, and Canada, increased mortality among older people living with HIV is often attributed to increased prevalence of illnesses such as cardiovascular disease, and kidney and liver failure, which can worsen HIV disease progression. These older people are also at greater risk of infectious diseases, such as tuberculosis."
NOTES TO EDITORS
The study was funded by the European Centre for Disease Prevention and Control, and it was conducted by researchers from the European Centre for Disease Prevention and Control.
 Belgium, Bulgaria, Czech Republic, Estonia, Germany, Greece, Hungary, Ireland, Latvia, Lithuania, Malta, Norway, Poland, Romania, Slovakia, and the UK. All country-level data is included in the Appendix.
 Quote direct from author and cannot be found in the text of the Article.
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