Abstract
Background
With the widespread availability of antiretroviral therapy (ART), HIV infection has become a manageable chronic condition, leading to a significant increase in the population of older adults living with HIV (OALHIV). Sexual health is a crucial yet often neglected dimension of comprehensive care for this group, as their sexual desire is rarely proactively assessed. Guided by the biopsychosocial model, this study aimed to identify factors associated with sexual desire among OALHIV.
Methods
A cross-sectional study was conducted at designated ART institutions in Luzhou, China, from May to November 2021. A total of 316 OALHIV (aged ≥ 50 years) were enrolled using convenience sampling. We designed a questionnaire to assess the sexual desire of OALHIV and the associated factors. Sexual desire was measured using a single binary item: “Do you currently have sexual desire?” (Yes/No). Chi-square test, t-test, and Fisher’s exact test were used for univariate analysis of sexual desire, and variables with statistical significance were included in binary logistic regression analysis to determine the factors associated with sexual desire.
Results
Among the 316 participants, 31.6% reported having sexual desire. Multivariate logistic regression analysis revealed that younger age (OR = 0.907, 95% CI: 0.872–0.943), male gender (OR = 3.395, 95% CI: 1.665–6.924), and higher life satisfaction (OR = 1.561, 95% CI: 1.268–1.923) were significantly associated with increased odds of reporting sexual desire. Compared with the lowest income group (< 1000 RMB), middle-income groups (1001–3000 RMB) had significantly higher odds of reporting sexual desire, suggesting an inverted U-shaped association.
Conclusion
Sexual desire is prevalent among over 30% of OALHIV, challenging societal stereotypes of “asexual aging”. Younger age, male gender, higher life satisfaction, and a middle-income level (in an inverted U-shaped pattern) are significantly associated factors. The biopsychosocial model offers a comprehensive framework for understanding these multifaceted factors. These findings underscore the importance of integrating sexual health assessment into routine geriatric HIV care and developing gender-sensitive, age-specific interventions to improve overall well-being in this growing population. However, the single-item measure may not capture the full multidimensional nature of sexual desire, and this limitation should be considered when interpreting the findings.
Keywords: HIV, Older adults, Sexual desire, Aging, Biopsychosocial model
Introduction
With the widespread availability of antiretroviral therapy (ART), HIV infection has become a manageable chronic condition, leading to a significant increase in life expectancy for people living with HIV (PLHIV) [1]. This has contributed to the rapid growth of the global population of older adults living with HIV (OALHIV, ≥ 50 years old) [2]. This demographic shift necessitates a transformation in HIV response strategies—from focusing primarily on young and middle-aged adults to also addressing the sizable and growing older population. The health needs of OALHIV are complex and unique, extending far beyond viral suppression to encompass comprehensive dimensions such as chronic disease management, functional maintenance, and socio-mental well-being, posing new challenges to existing public health and clinical care systems.
The OALHIV faces a “double burden” from the synergistic effects of aging and chronic infection [3]. Physiologically, they are more susceptible to multimorbidity, cognitive decline, and the phenomenon of “accelerated aging,” partly associated with chronic inflammation from long-term HIV infection and potential side effects of ART [4]. On the psychosocial front, issues such as internalized stigma, social isolation, depression, anxiety, and economic instability are particularly prominent [5]. These intertwined physiological, psychological, and social factors collectively undermine their overall health-related quality of life, highlighting the urgency for multidimensional health assessment for this group.
Within the comprehensive health assessment of OALHIV, sexual health is a crucial yet long-neglected dimension. Constrained by the social stereotype of “asexual aging” and the clinical neglect of non-reproductive sexual health issues among PLHIV, the sexual desire, functioning, and related psychosocial distress of this group are rarely proactively inquired about or discussed [6, 7]. However, sexual health is closely linked to an individual’s physical function, quality of intimate relationships, mental health, and life satisfaction. For older PLHIV, the presence or absence of sexual desire and its associated factors as an important indicator of their physical capacity, psychological adjustment, and social integration, and should therefore be an indispensable component of holistic care.
To comprehensively understand the determinants of sexual desire among OALHIV, this study is guided by the biopsychosocial model [8], which posits that health outcomes result from the dynamic interplay of biological, psychological, and social factors. This framework is particularly relevant for OALHIV because they experience the synergistic effects of aging and chronic HIV infection. Biologically, age-related physiological changes and HIV/ART-related effects may influence sexual function; psychologically, factors such as life satisfaction, internalized stigma, and mental health status may shape sexual desire; and socially, gender norms, having a spouse or not, and social support networks may either facilitate or constrain sexual expression.
Guided by the biopsychosocial model, we hypothesize that several factors may be associated with sexual desire in OALHIV. Biologically, younger age and better self-rated health may reflect preserved physical function and hormonal status, which could support sexual desire. Psychologically, higher life satisfaction may enhance sexual motivation through positive affect and reduced depressive symptoms, whereas internalized HIV-related stigma may suppress sexual desire by fostering shame, self-isolation, and withdrawal from intimate relationships. Socially, having a spouse may provide opportunities for partnered sexual expression and emotional intimacy, while social support from family or friends may buffer stress and promote overall well-being, indirectly facilitating sexual desire. Conversely, living alone may reduce both opportunity and motivation for sexual activity. Additionally, having more children may influence sexual desire through complex pathways, such as increased family responsibilities or perceived social roles, though the direction of this association remains unclear. These hypothesized associations justify the inclusion of the key variables in our analysis.
This study aims to identify the sociodemographic, health, and psychosocial factors significantly associated with their sexual desire through empirical analysis. The findings will help dispel misconceptions and provide key evidence for developing an age-specific, comprehensive care model, ultimately aiming to improve the overall quality of life and health outcomes of this growing population.
Methods
Study design and participants
A cross-sectional study was conducted at designated antiretroviral therapy (ART) medical institutions for HIV in Luzhou City, Sichuan Province, China, from May to November 2021. Participants were elderly individuals (≥ 50 years) living with HIV who were under ART follow-up management. Convenience sampling was used to recruit OALHIV on-site. Specifically, all eligible OALHIV who visited the ART medical institutions for HIV during the study period were invited to participate, and those who provided informed consent were enrolled. No additional selection criteria were applied beyond the inclusion and exclusion criteria. Inclusion criteria are: (1) Age ≥ 50 years; (2) living with HIV; (3) Ability to complete the questionnaire independently or with assistance. Exclusion criteria include: history of severe psychiatric disorders that may impair cognitive function or informed consent capacity (e.g., epilepsy, schizophrenia). Using the events per variable (EPV) criterion [9], our sample of 316 participants provided 100 events for 7 independent variables (EPV ≈ 14.3), exceeding the recommended minimum of 10 and indicating adequate sample size for stable logistic regression.
Measures
This study is one of a series of research projects addressing the geriatric needs of OALHIV. Therefore, the questionnaire used in this study was not specifically designed for this purpose. Our team has previously published papers on the preferences of OALHIV for care models and the requirements for geriatric nursing [10, 11]. Guided by the biopsychosocial model [8], our analysis examined variables across three domains: (1) biological factors (age, gender, number of chronic diseases, CD4 + T cell count, self-rated health), (2) psychological factors (life satisfaction, HIV-related stigma), and (3) social factors (having a spouse or not, number of children, living alone status, social support, personal monthly income). This theoretical framework informed our variable selection and guided our interpretation of the multivariate associations.
The Social Support Scale (SSRS) is a standardized and validated instrument originally developed by Xiao [12]. It consists of 10 items measuring three dimensions: objective support (e.g., “How many close friends around you can offer you support and assistance?“), subjective support (e.g., “How much support do you receive from your family?“), and support utilization (e.g., “When you are in need, do you seek help from others?“). Total scores range from 12 to 66, with higher scores indicating greater social support. The scale has demonstrated good reliability in previous studies (Cronbach’s α = 0.815). In our sample, the Cronbach’s α was 0.742. We used this scale to explore the association between social support and sexual desire.
The abbreviated Berger HIV Stigma Scale (Simplified Berger HIV Stigma Scale, SBHSS) was adapted and validated in a Chinese multi-ethnic population by Li Li and Guo Yan [13]. The scale contains 15 items with dichotomous response options (“agree” = 1, “disagree” = 0). It measures four dimensions: (1) rejection of people living with HIV (e.g., “Once people know I am infected, they avoid contact with me”), (2) negative self-image (e.g., “Having HIV makes me feel unclean”), (3) concern with disclosure (e.g., “I try to keep my HIV infection a secret”), and (4) harm from disclosure (e.g., “People’s reactions when they learn I have HIV have hurt me”). Total scores range from 0 to 15, with higher scores indicating higher perceived stigma. The original validation study reported a Cronbach’s α of 0.78. In our sample, the Cronbach’s α was 0.825. We used this scale to investigate the association between HIV-related stigma and sexual desire.
Sexual desire was conceptually defined as the subjective experience of libido or motivation for sexual activity, consistent with the World Health Organization’s sexual health framework, which emphasizes sexual well-being as an integral component of overall health [14]. Given the exploratory nature of this study, the cultural sensitivity of discussing sexuality among older Chinese adults, and the practical constraints of a broader questionnaire covering multiple domains, a single-item binary measure was selected. Single-item measures of sexual outcomes have been successfully used in sexual studies [15–17], and have demonstrated basic validity with minimal missing data when compared to comprehensive multi-dimensional instruments [17]. However, we acknowledge that a single item does not capture the multi-dimensional nature of sexual desire (e.g., frequency, intensity, context), and this limitation is addressed in the Discussion. Thus, sexual desire was measured through a single binary item: “Do you currently have sexual desire?” with response options “Yes” or “No”. This item was designed to capture the subjective experience of sexual desire, rather than sexual behavior, satisfaction, or intimacy.
Statistical analysis
Data were analyzed using SPSS 21.0. Univariate analyses (chi-square test for categorical variables or Fisher’s exact test, t-test for continuous variables) were conducted to identify variables associated with sexual desire (p < 0.05). Variables with statistical significance in univariate analysis were entered into a binary logistic regression model to assess their association with sexual desire. The dependent variable, “Do you experience sexual desire?“, was coded as 1 (Yes) or 0 (No). Independent variables included gender (1 = Female, 2 = Male), age (continuous), education level (categorical), household registration type (urban/rural), living alone status (categorical: 1 = yes, 0 = no), having spouse or not (categorical: 1 = yes, 0 = no), number of children (continuous: 0–5, the number indicates the number of children), personal monthly income (categorical), number of chronic diseases (categorical), duration since HIV diagnosis (categorical), CD4 + T cell count (categorical), self-rated health (ordinal), and life satisfaction (ordinal). All categorical variables were entered as dummy variables. Statistical significance was set at p < 0.05.
Ethics
Based on the principle of anonymity and informed consent, this study has been approved by the Ethics Committee of the Affiliated Hospital of Southwest Medical University with ethical approval number KY2021072.
Results
Characteristics of the respondents
Table 1 presents the general characteristics of the respondents and the results of the univariate analysis. A total of 316 OALHIV were enrolled (mean age: 64.59 ± 8.7 years; sexual desire prevalence: 31.6%, n = 100). Univariate analyses identified seven factors significantly associated with sexual desire (P < 0.05): younger age, male gender, having a spouse, number of children, personal monthly income, better self-rated health, and higher life satisfaction. Life satisfaction demonstrated the strongest association (χ²= 28.744, P < 0.001), with sexual desire reported by 57.3% of “very satisfied” participants versus 20.0% of “very dissatisfied” participants. No significant associations were observed for education, household registration, living alone status, number of chronic diseases, HIV diagnosis duration, CD4 T cell count, total social support score, and total HIV stigma score (P > 0.05).
Table 1.
General characteristics of respondents and univariate analysis of sexual desire(n = 316)
| Variable | Frequency, n (%) | Sexual desire (n) | t / χ2 | P | |
|---|---|---|---|---|---|
| No (n = 216) | Yes (n = 100) | ||||
| Age (years), mean ± SD | 64.59 ± 8.70 | 66.41 ± 8.56 | 60.67 ± 7.67 | 12.08 | < 0.001 |
| Gender | |||||
| Female | 85 (26.9) | 66 (77.6) | 19 (22.4) | 4.641 | 0.031 |
| Male | 231 (73.1) | 150 (64.9) | 81 (35.1) | ||
| Education† | |||||
| Primary school and below | 209 (66.1) | 149 (71.3) | 60 (28.7) | - | 0.372 |
| Junior high school | 76 (24.1) | 49 (64.5) | 27 (35.5) | ||
| Senior high school | 24 (7.6) | 14 (58.3) | 10 (41.7) | ||
| Junior college and above | 7 (2.2) | 4 (57.1) | 3 (42.9) | ||
| Household registration | |||||
| Urban | 130 (41.1) | 86 (66.2) | 44 (33.8) | 0.494 | 0.482 |
| Rural | 186 (58.9) | 130 (69.9) | 56 (30.1) | ||
| Whether living alone | |||||
| Yes | 105 (33.2) | 78 (74.3) | 27 (25.7) | 2.557 | 0.110 |
| No | 211 (66.8) | 138 (65.4) | 73 (34.6) | ||
| Having a spouse or not | |||||
| No | 115 (36.4) | 87 (75.7) | 28 (24.3) | 4.451 | 0.035 |
| Yes | 201 (63.6) | 129 (64.2) | 72 (35.8) | ||
| Number of children† | |||||
| 0 | 17 (5.4) | 13 (76.5) | 4 (23.5) | - | 0.012 |
| 1 | 141 (44.6) | 86 (61.0) | 55 (39.0) | ||
| 2 | 115 (36.4) | 79 (68.7) | 36 (31.3) | ||
| 3 | 28 (8.9) | 26 (92.9) | 2 (7.1) | ||
| 4 | 6 (1.9) | 5 (83.3) | 1 (16.7) | ||
| 5 | 9 (2.8) | 7 (77.8) | 2 (22.2) | ||
| Monthly income (RMB) | |||||
| <1000 | 118 (37.3) | 92 (78.0) | 26 (22.0) | 9.936 | 0.042 |
| 1001–2000 | 89 (28.2) | 55 (61.8) | 34 (38.2) | ||
| 2001–3000 | 43 (13.6) | 24 (55.8) | 19 (44.2) | ||
| 3001–4000 | 41 (13.0) | 28 (68.3) | 13 (31.7) | ||
| >4000 | 25 (7.9) | 17 (68.0) | 8 (32.0) | ||
| Number of chronic diseases† | |||||
| 0 | 11 (3.5) | 9 (81.8) | 2 (18.2) | - | 0.058 |
| 1–3 | 143 (45.3) | 88 (61.5) | 55 (38.5) | ||
| ≥ 4 | 162 (51.3) | 119 (73.5) | 43 (26.5) | ||
| Time since HIV diagnosis, years | |||||
| <1 | 62 (19.6) | 38 (61.3) | 24 (38.7) | 2.369 | 0.502 |
| 1–3 | 142 (44.9) | 101 (71.1) | 41 (28.9) | ||
| 3–5 | 43 (13.6) | 28 (65.1) | 15 (34.9) | ||
| >5 | 69 (21.8) | 49 (71.0) | 20 (29.0) | ||
| CD4 + T cell count | |||||
| <200 | 49 (15.5) | 34 (69.4) | 15 (30.6) | 2.173 | 0.537 |
| 200–349 | 102 (32.3) | 71 (69.6) | 31 (30.4) | ||
| 350–499 | 77 (24.4) | 56 (72.7) | 21 (27.3) | ||
| ≥ 500 | 88 (27.8) | 55 (62.5) | 33 (37.5) | ||
| Self-rated health† | |||||
| Very poor | 11 (3.5) | 9 (81.8) | 2 (18.2) | - | 0.046 |
| Poor | 47 (14.9) | 35 (74.5) | 12 (25.5) | ||
| Fair | 86 (27.2) | 63 (73.3) | 23 (26.7) | ||
| Good | 109 (34.5) | 76 (69.7) | 33 (30.3) | ||
| Very good | 63 (19.9) | 33 (52.4) | 30 (47.6) | ||
| Life satisfaction | |||||
| very dissatisfied | 60 (19.0) | 48 (80.0) | 12 (20.0) | 28.744 | < 0.001 |
| somewhat dissatisfied | 54 (17.1) | 43 (79.6) | 11 (20.4) | ||
| neutral | 79 (25.0) | 55 (69.6) | 24 (30.4) | ||
| somewhat satisfied | 55 (17.4) | 41 (74.5) | 14 (25.5) | ||
| very satisfied | 68 (21.5) | 29 (42.6) | 39 (57.4) | ||
| Total social support score | 28.73 ± 7.01 | 28.25 ± 7.26 | 29.77 ± 6.36 | -1.805 | 0.072 |
| Total HIV stigma score | 9.74 ± 3.38 | 9.62 ± 3.57 | 10.01 ± 2.90 | -1.029 | 0.305 |
† indicates that Fisher’s exact probability test was used
Factors associated with sexual desire among OALHIV
From Table 2, multivariate binary logistic regression identified three significant factors associated with sexual desire (P < 0.05). Older age was negatively associated with sexual desire (OR = 0.907, 95% CI: 0.872–0.943, P < 0.01), indicating that older age was associated with lower odds of reporting sexual desire. Males had 3.40 times higher odds of reporting sexual desire than females (OR = 3.395, 95% CI: 1.665–6.924, P < 0.01). Additionally, greater life satisfaction was positively associated with sexual desire (OR = 1.561, 95% CI: 1.268–1.923, P < 0.01). From the perspective of the biopsychosocial model, these significant factors map onto the biological (age), social (gender as a social construct), and psychological (life satisfaction) domains, respectively. Having a spouse or not, number of children, and self-rated health were not statistically significant (P > 0.05). For monthly income, compared to the lowest income group (< 1000 RMB), the middle-income groups (1001–2000 RMB and 2001–3000 RMB) showed significantly higher odds of reporting sexual desire, while the higher income groups (3001–4000 RMB and > 4000 RMB) did not differ significantly from the reference group, suggesting an inverted U-shaped association.
Table 2.
Binary logistic regression analysis of sexual desire among OALHIV
| Characteristics | OR | 95%CI | p |
|---|---|---|---|
| Age (years) | 0.907 | 0.872–0.943 | < 0.01 |
| Gender | |||
| Female (ref) | 1.00 | ||
| Male | 3.395 | 1.665–6.924 | < 0.01 |
| Having a spouse or not | |||
| No (ref) | 1.00 | ||
| Yes | 1.586 | 0.879–2.862 | 0.126 |
| Number of children | 0.904 | 0.646–1.264 | 0.554 |
| Monthly income (RMB) | |||
| < 1000 (ref) | 1.00 | ||
| 1001–2000 | 2.562 | 1.279–5.131 | < 0.01 |
| 2001–3000 | 2.808 | 1.189–6.632 | 0.019 |
| 3001–4000 | 0.661 | 0.250–1.743 | 0.402 |
| > 4000 | 0.618 | 0.195–1.961 | 0.414 |
| Self-rated health | 1.198 | 0.909–1.578 | 0.199 |
| Life satisfaction | 1.561 | 1.268–1.923 | < 0.01 |
OR Odds ratio, CI Confidence interval, ref reference category
Discussion
Our data show that 31.6% of all OALHIV reported having sexual desire. Among male OALHIV, 35.1% expressed having a sexual desire, which is lower than the 46.8% of men aged ≥ 50 years in the general Chinese population who were sexually active in the past year [18]. Applying the biopsychosocial model as an interpretive lens, considering potential negative effects of HIV infection on sexual function and the social desirability bias against reporting sexuality in older Chinese adults, the actual proportion with sexual desire may be higher. Multiple studies [19–21] consistently indicate that a significant proportion of OALHIV not only possess sexual desire but also maintain active sexual lives. These findings challenge societal stereotypes portraying older individuals, particularly those with chronic conditions, as ‘asexual’. Traditional social culture constructs elderly people as “desexualized” beings, with the intersection of ageism and HIV-related stigma forming dual suppression of sexual health among OALHIV [22–24]. However, their sexual desires are genuine and constitute an integral part of their identity as complete human beings, deserving of acknowledgement and respect. The World Health Organization (WHO) has emphasized that sexual health is an inherent part of overall well-being, and this principle applies equally to OALHIV [25]. Thus, healthcare providers should abandon outdated prejudices and integrate sexual health assessment into routine geriatric HIV care, as unmet sexual desire can undermine overall quality of life.
Our multivariate logistic regression analysis revealed that younger age is a significant positive predictor of sexual desire among OALHIV (OR = 0.907, 95% CI: 0.872–0.943, P < 0.01), indicating that each one-year increase in age is associated with a 9.3% decrease in the likelihood of reporting sexual desire. From the biological dimension of the biopsychosocial model, this finding aligns with the general aging trend observed in sexual health research, as sexual activity frequency tends to decline with advancing age [26, 27] due to physiological changes such as reduced hormone levels and increased comorbidities [28]. Specifically for older PLHIV, age-related declines in physical function may be exacerbated by HIV infection and antiretroviral therapy (ART), further affecting sexual desire and performance [29]. A study conducted in Chongqing, China [30], also identified that individuals aged 50–59 years had significantly higher odds of sexual desire compared to older age groups (OR = 14.688, 95% CI: 4.887–44.143). This indicates that relatively younger individuals among OALHIV may constitute a key target group for sexual health interventions, as they retain relatively higher sexual desire. Healthcare providers should tailor sexual health education and support to different age subgroups among older PLHIV, addressing age-specific physiological and psychological barriers to sexual expression.
The study found that gender was associated with sexual desire among older HIV-infected individuals, with males reporting a significantly higher rate of sexual desire (OR = 3.395) than females. This finding is consistent with previous studies on older HIV-infected individuals [31, 32]. However, this significant statistical difference cannot be simply attributed to biological determinism such as hormone levels. Instead, it must be examined within a broader framework of social cultural power dynamics and gender norms. Following Connell’s (2005) theory of hegemonic masculinity [33], in many sociocultural contexts, male sexuality is constructed as active, persistent, and vibrant, forming a core component of masculine identity, even in old age [34]. This societal expectation legitimizes and validates older males’ expression of sexual desire. In contrast, female sexuality is often defined as passive, relationship-oriented [35], and closely tied to reproductive function [36]. After menopause, women’s “sexual subjectivity” is further undermined by sociocultural norms, and their expressions of sexual desire are more easily deemed “inappropriate” or “immoral” [37]. Therefore, the lower reporting rate among females in this study may not only reflect their genuine inner feelings but also represent an internalized gender script—females may suppress or deny their sexual desire due to anticipated social disapproval or stigma. This gendered power imbalance grants older males greater discursive power and less social resistance when discussing and reporting their sexual desire [38].
Moreover, the gender differences observed in this study reflect the interplay of structural stigma and intersectionality. For HIV-infected individuals, stigma is a core socio-psychological challenge [39]. However, its impact is not homogeneous; it is modulated by multiple intersecting identities such as gender, age, and social class. According to Link & Phelan’s (2001) theory, stigma is not just an individual-level prejudice but a force rooted in social structures and institutions [40]. It deprives stigmatized groups of social capital and opportunities, exerting a persistent negative impact on health and well-being. For older female participants in this study, they may face a triple intersection of ageism (older adults are “asexual”), gender discrimination (older women should not have sexual desire), and HIV-related stigma (linking infection to immoral behavior) [41, 42]. This intersectional stigma creates a strong structural barrier that not only limits their access to sexual health services—healthcare providers may, due to inherent biases, never proactively inquire about older women’s sexual health [43]—but also leads to deep self-stigma, causing them to fundamentally question their right to have and express sexual desire [44]. In contrast, while older male HIV-infected individuals also bear the dual stigma of age and disease, society’s higher tolerance for male sexuality may buffer the impact of this structural pressure to some extent [38]. Therefore, the observed gender differences are actually differential outcomes of social structural forces acting upon different genders, reflecting the deeper social vulnerability that women experience when confronting multiple marginalized identities [45]. These findings underscore the need for structural and culturally sensitive interventions: policies should mandate routine sexual health assessments for all OALHIV with attention to older women; healthcare systems must train providers to recognize gender biases; and community programs should destigmatize older women’s sexuality. Future research should incorporate measures of power dynamics, structural stigma, and cultural norms to quantitatively test these pathways.
Our analysis also revealed a non-linear association between monthly income and sexual desire. Compared with the lowest income group (< 1000 RMB), participants in the middle-income brackets (1001–2000 RMB and 2001–3000 RMB) had significantly higher odds of reporting sexual desire (OR = 2.562 and 2.808, respectively), whereas those in higher income groups (≥ 3001 RMB) did not differ significantly from the reference. This pattern suggests an inverted U-shaped relationship, where sexual desire peaks in the middle-income range and declines at both low and high extremes. This finding aligns with the broader social science literature showing an inverted U-shaped association between income and various health outcomes, including subjective well-being, life satisfaction, and mental health [46, 47]. For very low income, financial insecurity and basic survival concerns [48, 49] may suppress sexual desire by increasing stress and reducing opportunities for intimacy. Conversely, very high income may be associated with longer working hours, greater occupational pressure [50], that leave less time and energy for sexual expression. Furthermore, income has been clearly demonstrated to have an impact on life satisfaction and mental health [51, 52], which in turn may indirectly affect sexual desire. These findings highlight the importance of considering income not as a simple linear predictor but as a social determinant with a nuanced, non-linear influence on sexual desire in OALHIV.
Our findings indicate that higher life satisfaction is significantly associated with increased sexual desire among older PLWH (OR = 1.561, 95% CI: 1.268–1.923, p < 0.01). From the psychological dimension of the biopsychosocial model, this result aligns with existing literature, which consistently demonstrates a positive relationship between overall life satisfaction and sexual activity in older adults. For instance, the WHO’s systematic review confirming strong correlations between sexual health and overall well-being across populations [25]. Skałacka and Gerymski [53] found that sexual activity levels are positively correlated with overall life satisfaction among individuals aged 60 and above. This suggests that the desire for sexual intimacy may be related to an overall perception of well-being and satisfaction with life circumstances. Furthermore, the interplay between life satisfaction and sexual desire appears to be mediated by mental health factors. In our study, the positive association between life satisfaction and sexual desire may reflect better mental health and lower depressive symptoms, which are known to correlate with enhanced sexual desire. This is supported by research from Kim et al., who reported that higher life satisfaction is linked to better psychosocial health outcomes in older adults [54], potentially facilitating healthier sexual behavior and reduced sexual distress. The findings also echo the work of Milewska-Buzun et al., who emphasized that sexual satisfaction is a crucial component of quality of life in PLWH [55], suggesting that interventions aimed at improving overall life satisfaction may have a beneficial ripple effect on sexual health and intimacy needs.
Notably, neither HIV-related stigma nor social support showed significant associations with sexual desire in this study, which diverges from some theoretical expectations but can be plausibly explained when considering the biopsychosocial model’s emphasis on cultural and measurement contexts. First, cultural norms of sexual silence and “asexual aging” among older Chinese adults [56] may suppress explicit linkage between stigma or support and reported sexual desire, as such topics remain highly private and stigmatized even in supportive environments. Second, measurement limitations may have attenuated associations: the abbreviated stigma scale and general social support scale were not purpose-built to capture sexuality-specific stigma or intimate partner support, which are more proximally linked to sexual desire than general social support or global HIV stigma. Third, strong social desirability bias related to both HIV and late-life sexuality likely led to underreporting of sexual desire and constrained variance in stigma or support scores, reducing statistical power to detect associations. These interpretations align with prior studies showing that culturally embedded modesty, face concerns, and sensitivity around HIV and sexuality in older Chinese populations [39, 56] can mask relationships between psychosocial factors and sexual health outcomes. Future studies should employ sexuality-specific stigma measures, intimate-level support scales, and enhanced privacy protocols to reduce bias and improve measurement precision.
Conclusions
This study found that sexual desire is present among a notable proportion (31.6%) of OALHIV, challenging the societal stereotype of “asexual aging” in this population. Younger age, male gender, and higher life satisfaction were identified as significant associated factors. Explicitly guided by the biopsychosocial model, our study demonstrates that sexual desire in OALHIV is shaped by interconnected biological (age), social (gender), and psychological (life satisfaction) factors. This theoretical contribution enhances the field’s understanding of sexual health in aging populations with chronic conditions. These findings highlight the importance of integrating sexual health assessment into routine geriatric HIV care and suggest that healthcare providers should be attentive to the sexual health concerns of OALHIV, particularly among younger and male subgroups. Given the cross-sectional design, further longitudinal research is warranted to explore the causal pathways between life satisfaction and sexual desire, and to inform the development of age-appropriate, gender-sensitive interventions aimed at improving the overall well-being of this growing population.
Limitations
Several limitations of this study should be acknowledged. First, the cross-sectional design precludes the establishment of causal relationships between the identified factors and sexual desire; it only allows for the inference of associations, not causation. Second, the use of convenience sampling at ART institutions in a single city (Luzhou, Sichuan Province) may limit the representativeness of the sample and the generalizability of the findings to the broader population of OALHIV in other regions of China or other countries. Luzhou is a prefecture-level city in southwestern China, and its population characteristics, healthcare resources, and cultural attitudes toward sexuality and HIV may differ from those in large metropolitan areas (e.g., Beijing, Shanghai), rural regions, or other provinces. Moreover, convenience sampling may introduce selection bias, as participants who agreed to enroll might differ systematically from those who declined (e.g., in terms of openness about sexual health or overall health status). Therefore, our findings should be interpreted with caution when applied to OALHIV in different geographic, cultural, or healthcare settings. Third, sexual desire was measured using a single-item question, which may not fully capture the frequency, intensity, or multidimensional nature of sexual desire. Future research should focus on developing and validating a dedicated multidimensional scale for this population. Fourth, despite efforts to ensure privacy, the sensitive nature of the topic may have led to social desirability bias, potentially resulting in underreporting of sexual desire, particularly among female participants. Finally, while we controlled for several key variables, unmeasured confounders such as the use of specific medications that affect libido, the quality of intimate relationships, or detailed mental health status (e.g., depression) were not included in the analysis and could have influenced the results. Additionally, although the biopsychosocial model guided our analysis, the cross-sectional design limits our ability to test dynamic causal pathways within this framework. Future research should employ longitudinal designs, larger and more diverse samples, and comprehensive multidimensional measures of sexual health to better understand the complex relationship between sexual desire and associated factors among OALHIV.
Acknowledgements
The authors are grateful to all patients who participated in this study and the Centers for Disease Control and Prevention for their support of this program.
Abbreviations
- OALHIV
Older adults living with HIV
- PLHIV
People living with HIV
- ART
Antiretroviral Therapy
Authors’ contributions
All listed authors contributed significantly to the work. LM, WLH and YHC conceptualized and designed the study. YL, JLR and ZLY contributed to the data collection. ML and JLR performed data analysis. ML and YZ drafted the manuscript. ML, WLH and YHC contributed to the interpretation of results. ML, YL, JLR and YZ provided critical manuscript revision. SW, XHP and ZLY contributed to data re-analysis, manuscript revision, and response to reviewer comments. All authors read and approved the final manuscript.
Funding
This research was supported by Sichuan Provincial Natural Science Foundation Project (General Program): 2024NSFSC0571A and Project of the Philosophy and Social Sciences Federation of Sichuan Province (SCJJ25ND215).
Data availability
The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
This study was performed according to the principles of Helsinki Declaration and approved by the Ethics Committee of the Affiliated Hospital of Southwest Medical University with ethical approval number KY2021072. Informed consents were obtained from all participants prior to questionnaire administration.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Mei Li, Shan Wu and Xiaohui Peng contributed equally to this work.
Contributor Information
Zhaolan Yu, Email: 310935403@qq.com.
Yanhua Chen, Email: chen_yanhua25@163.com.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.