By Dr Joseph Matare
– Call for Action
Having entered the third decade of the seemingly unabating HIV epidemic, the lower than expected number of people that have voluntarily tested for HIV or who know their HIV status in Namibia, remains a cause for concern.
This is despite various implemented strategies including transition from predominantly client-initiated voluntary counselling and testing (VCT) to provider-initiated VCT; social marketing and mass media advertising; establishment of VCT centres offering free services and specific programmes targeted at perceived at-risk groups in the population (e.g. sex workers, truck drivers, etc.).
It is the backdrop of low HIV testing amongst Namibians that has prompted the Ministry of Health and Social Services (MoHSS) to inaugurate a national HIV testing day this year; to be subsequently commemorated annually as a way of mobilizing citizens to voluntarily test for HIV.
This year it will be on May 09, 2008 and various stakeholders are working hard on making this day a huge success. As a front line health worker in the field, I am afraid the same groups that are perceived to be at high risk of HIV will be targeted again this year. These are people in the 15- 49 age group, deemed to be the most sexually active and thus at higher risk of heterosexual HIV infection in our setting.
It is acceptable to re-focus on that group given the low testing rates. However, one group has been overlooked over the years. It is the elderly people, those over 50 years old and the pensioners. There are barriers that need to the exposed and explored. That is the subject of this discussion, as the landmark day approaches and as preparations for the day gather momentum.
Older people tested and infected with HIV
Literature is replete with data showing the number of the elderly people living with HIV/AIDS (EPLWHA) is increasing worldwide. UNAIDS estimates show that 7% of all HIV persons are aged 50 years and older globally.
In the USA, estimates put the prevalence at 15%. One author stated that data from low-income countries are few. However, in Uganda, 4.6% of clients tested for HIV between 1999 and 2002 were older than 50 years with an HIV prevalence of 20%.
The South African national household HIV survey found an HIV prevalence of about 20% in the elderly.
In Namibia, data from a VCT centre in a predominantly rural setting shows that 17% were 49 years and older and the HIV prevalence was 29%.
Geographical differences are expected given that in our society, most of the elderly or pensioners retire to or reside in rural villages.
HIV infection risk in older people
Heterosexual sex remains the predominant mode of HIV transmission in the older people. In our discussions in the clinical setting, including discussions with elderly men, it is prominently clear that older men receiving old age pensions are at particular risk since they engage in transactional intergenerational sex with younger women.
Condoms are not used by most, because, according to some old men conversed with, they do not know how to use them.
Old women would generally, but not exclusively, get exposed to HIV during care of the sick people at home, or during the conduct of home deliveries and other bloody traditional practices.
Barriers to HIV testing in the elderly
It is well documented that HIV testing rates in elderly people are much lower compared to younger people because communities in general and health workers in particular presume the elderly are at low risk of HIV.
This notion is spurred by the erroneous assumption that older people are no longer sexually active. As a result, the elderly fail to accrue the benefits of early diagnosis of HIV; and thus miss out on early treatment, care and support.
Making a clinical diagnosis of HIV in the elderly may indeed be a challenge. The signs and symptoms of HIV in the elderly resemble those associated with the normal process of aging.
Many researchers also note with despair that WHO guidelines on HIV testing in populations do not seem to accord HIV infection amongst the elderly the priority and prominence it now deserves.
Readers may have observed the stereotyping of the elderly people in advertorials regarding HIV in mass media. Most often they are portrayed as the carers, rarely, if ever, as the infected.
This approach has clouded the reality that the elderly also need HIV care for themselves. The perpetuation of the notion that the elderly do not have HIV only exposes them to the risk of stigma and death through missing out on available free HIV/AIDS care and treatment.
Social barriers and taboos are a distinct barrier for the elderly to be tested for HIV. Most health and allied workers in the field happen to be young people who are culturally barred from discussing sex with the elderly.
However, some elderly patients conversed with are willing to be involved in peer or support groups or networks through which these social barriers may be overcome. Some are even prepared to appear in adverts or videos in order to highlight the plight or problem of HIV/AIDS in the elderly.
Early diagnosis and implications for clinical management
The aged people are considered a debilitated host as a result of the normal process of aging, compounded, in some cases, by more than one chronic degenerative ailment. HIV-associated immunosuppression aggravates progressive immune deficiency associated with aging.
Through late testing and late diagnosis, many studies have shown that the elderly are usually in advanced AIDS stages with low CD4 counts when they present for care.
Age of the HIV-infected individual at the time of starting HIV treatment is one of the known predictors for the speed and extent of immune recovery. There is a plethora of evidence from studies in many settings that have shown that the elderly take longer to recover and the maximal CD4 is not reached that easily.
The stunted recovery has been shown to be a result of the reduction in the size and activity of the thymus gland that occurs progressively as the person grows older. CD4 lymphocytes are produced and mature in this gland.
With a larger and more active thymus gland, children, despite suboptimal treatment adherence, comparatively recover immunologically much more rapidly on antiretroviral therapy compared to the adult persons. However, attempts to transplant it from one person to another have been largely unsuccessful.
When HIV treatment is started, the benefits with respect to reduction in deaths have been shown to be much higher in the elderly than in younger patients.
This is because without treatment, the elderly die much more.
Existing clinical guidelines do not consider the elderly as a special group and thus are subjected to the same rules. There is room for research in our setting, including clinical trials, in the elderly to ascertain the optimal strategies to treat them better.
The burden of HIV/AIDS in the elderly in Namibia is real and possibly increasing and we should shift our mindset from believing the elderly are only carers of HIV-infected people to acknowledging that they are themselves affected with HIV/AIDS.
We need to proactively involve them in the HIV response by involving other elders living with HIV/AIDS to approach their peers, and use them in adverts and promotional videos. Late testing of HIV in the elderly puts them at risk of unnecessary and preventable illnesses and death related to HIV/AIDS.
The basket of barometers to evaluate the success of the national testing day should also include the proportion of the elderly persons older than 50 years in our population who have been tested for HIV.
A paradigm shift in mindset and approach is thus obligatory in order to meet the needs of the elderly people living with HIV in our country.
– Opinion article written in view of the impending national HIV testing day, 9 May 2008. Author is an HIV clinician with interests in public health and research. He can be contacted at email@example.com