Addressing HIV Infection Risksand Consequences Among Elderly(> 50 years) Sub-Saharan Africans PROFESSOR NIYI AWOFESO SCHOOL OF POPULATION HEALTH UNIVERSITY OF WESTERN AUSTRALIA. INTERNATIONAL SEMINAR ON “SOCIO ECONOMIC AND MENTAL HEALTH BURDENS OF HIV-AIDS IN DEVELOPING COUNTRIES”: KUALA LUMPUR, 21 NOVEMBER 2011.
Presentation OutlineBasic health statistics about AfricaHIV/AIDS epidemiology among the elderly(> 50 years) in Sub-Saharan Africa (SSA).Physical, mental health and socio-economicburdens of HIV/AIDS among SSA’s elderly.Evidence-based policies and programs toaddress socio-economic burdens andHIV/AIDS infection risks among SSA’selderly, including lessons from Asia-Pacificexperience
Sub-Saharan Africa – Basic Statistics (WHO-AFRO, 2011)
Basic Statistics – African Region (WHO-AFRO, 2011)
Basic Statistics – African Region (WHO-AFRO, 2011)
Basic Statistics – African Region (WHO-AFRO, 2011)Life expectancy at birth, by region & by gender.
Basic Statistics – African Region (WHO-AFRO, 2011)Per capita total expenditure Total health expenditureon health (PPP). as % of GDP.
Basic Statistics – African Region (WHO-AFRO, 2011)Physician-to-population Nursing and midwiferyratio (per 10,000 personnel-to-populationpopulation) in WHO ratio (per 10000Regions, 2000–2009 population) in WHO Regions, 2000–2009
Basic Statistics – African Region (WHO-AFRO, 2011)HIV/AIDS mortality rate HIV/AIDS mortality rate(per 100000 population) in (per 100000 population)the African Region, 2007. in WHO Regions, 2007
Extent of HIV/AIDS among SSA’s elderlyAbout 3 million elderly individuals in Africa are livingwith HIV infection, approximately 10% of all HIVinfections (Negin & Cumming, 2009).The estimated prevalence of HIV infection among SSA’selderly and those aged 15-49 are similar at about 5%.The proportion of elderly people in Africa infected withHIV/AIDS is increasing: good news because increasedaccess to treatments means that patients are living withlonger life expectancy; bad news because meeting thecomplexities of geriatric care for HIV-infected adultswill further challenge overwhelmed health systems.
HIV/AIDS Among SSA’s elderly (> 50 years)Source: Demographic Health Surveys, 2003-7(Rammohan % Awofeso, 2010).
HIV Prevalence Among SSAs over 50 years old (Negin & Cumming, 2010).
SSA’s Demographic Transition – over 60yoSource: UN WPT, 2004,and NAS, 2007.
HIV/AIDS and Africa’s Demographic Transition(erroneous) Modelled Life expectancy trends inselected African nations & WB 2009 estimate forSouth Africa:
HIV/AIDS Among Elderly SSAsElderly SSAs constitute ~ 4.7% of the generalpopulation & 5% of the total adult population infectedwith HIV.Based on limited data on elderly SSA males obtainedfrom DHS 2003 – 2007 surveys, HIV prevalenceamong SSA’s elderly ranged from 1% in Ethiopia to 19%in Zimbabwe.A 2001-2 sero-survey of 133 male Ethiopian cataractpatients aged 50-59 found HIV prevalence of 9.1%,higher than the 1% prevalence reported in the DHS, aswell as a 6.3% HIV prevalence in Ethiopians aged 15-49years (?? HIV associated cataract. Rasmussen et al, 2011)
HIV/AIDS Among Elderly SSAsKenya’s DHS 2003 data documented male HIVprevalence as 4·6% for the 15—49 year age-group, and5·7% for the 50—54 year age-group.The prevalence of HIV notification in men aged 50—54years rose sharply between 2003 and 2008 (from 5·7%to 9·1%), while younger cohorts were generally static ordeclining in prevalence.HIV prevalence was highest in the wealthiest quintileand increased in both cohorts for the two survey periods.Further, over 60% of men aged 50—54 years who testedpositive lived in rural areas. – Mills, Rammohan,Awofeso, Lancet, 2010.
“Risk factors” for HIV infection among SSA’s elderlySource: Rammohan & Other risk factors:Awofeso, TD, 2010 Food insecurity Rural location Poverty Injecting drug use Lack of circumcision in males, & vaginal thinning in females. Healthy ageing Senescence
Physical burden of HIV among SSA’s elderlyWasting syndromeIncreased vulnerability to infections:Tuberculosis, Malaria, Giardia, Salmonella,Cytomegalovirus, Candida, Cryptococcal meningitis,Toxoplasmosis, Cryptosporidiosis.Increased vulnerability to cancers: Kaposissarcoma, Lymphomas.Neurological complications: AIDS dementiacomplex, Vascular myelopathy, Peripheralneuropathies.
Physical burden of HIV among SSA’s elderly – Wasting SyndromeWasting syndrome isdefined as weight lossin excess of 10% frombaseline that isassociated withchronic diarrhoea,fever, or weakness.Second most commonAIDS-associatedcondition in SSA.
Mental Health Burden of HIV/AIDS (WHO, 2008)In United States, prevalence of mental illnessamong HIV+ve patients range from 5% and23%, compared with 0.3% to 0.4% in thegeneral population.Mental health problems & substance abusedouble behavioural risk factors for HIV spread.Studies in both low- and high-income countrieshave reported higher rates of depression &psychological distress in HIV-positive peoplecompared with HIV-negative control groups.
Mental Health Burden of HIV/AIDS (WHO, 2008)Mental health problems impair care seeking &treatment adherence among those diagnosed withHIV/AIDS.Direct effects of HIV on the brain include: HIVencephalopathy, depression, mania, cognitivedisorder, and frank dementia, often incombination.Mental illnesses like depression and drug addictioncan themselves be risk factors for HIV. Conversely,people with HIV are more likely to develop mentalillness than the general population.
Mental Health Burden of HIV/AIDSThere are no specific mental health servicesfor people living with HIV in SSATraining of African healthcare workers onmental health problems associated with HIV isinadequate.A 2008 study by South Africas HumanSciences Research Council found that 44% of asample of 900 HIV-positive individuals weresuffering from a mental disorder (Freeman,2008).
Mental health burden of HIV/AIDS: AIDS-related cognitive disorder & dementia (American Academy of Neurology, 2007) A-RCD may be prelude to frank dementia.Symptoms include: motor dysfunction, such as muscle weakness Poor performance on regular tasks Increased concentration and attention required Reversing of numbers or words Slower responses and frequently dropping objects General feelings of indifference or apathy
Economic Burden of HIV/AIDS Among SSA’s ElderlyAmong SSA’s elderly, economic status has a bimodalinfluence on HIV transmission. Thus, burden varieswidely. Nevertheless, HIV infection is associated withsocio-economic disadvantage in all wealth quintiles
Economic Burden of HIV/AIDS Among SSA’s Elderly CaregiversIn a recent study in Kenya, About 11% of older peoplereported to have provided care to someone with a chronicillness, out of whom 41% were classified as having cared forsomeone with a HIV/AIDS. Health care costs weresignificantly higher among HIV/AIDS caregivers(Chepngeno-Langat et al, 2010).Caregiving is associated with depressed economic statusamong SSA’s elderly, except in societies with strong extendedfamily ties, free HIV treatment or wealthy patients.
Social Burden of HIV infection – Stigma & Discrimination“. . . a Bangladesh village was evacuated and a hospital was set on fire when hysterical residents found out that five villagers were diagnosed with HIV. Police detained a suspected AIDS patient in the Sylhet district and took him to an infectious diseases hospital, but the patient fled when protestors threatened to burn down the hospital. The hospital staff also panicked and claimed they would not treat anyone with AIDS. The Persian Gulf sheikdom of Dubai deported the five infected persons in early June after physicians had learned of their HIV-infected status. Three of the infected men did not disclose their conditions while receiving medical treatment because they feared they would be ‘‘burned to death by panic-stricken people.’’ – Ullah, 2011.
Social Burden of HIV infection – Stigma & Discrimination
HIV Status and Discrimination http://www.youtube.com/ watch?v=buQm23Nw49s
Social Burden of HIV/AIDS Among the ElderlyAverage decline in GDP in Africa due to HIV/AIDS hasso far oscillated around 1% per annum, due, in part, tolow labour costs and inadequate consideration of thenon-informal sector, and unpaid carers work by theelderly in such modelling.The presence of HIV/AIDS in a household may result ina depletion of household income earning capacity andof household savings and assets.The economic costs of HIV/AIDS, the stigmasurrounding the disease that leads to discriminationand social exclusion widen socio-economic inequalities.
Social Burden of HIV/AIDS Among SSA’s Elderly SSA’s elderly population is experiencing less care and support from their children and communities as the impact of HIV/AIDS and a weakening economy change family support structures. Sex education is regarded as a taboo topic among the elderly in many African societies, thus limiting opportunities for providing factual information on HIV transmission to this cohort. About 51% of all people living with HIV globally, and 61% of all HIV cases in SSA, being women. Poverty, gender inequality, powerlessness, weak public services, violence and political instability place SSA women at greater risk of HIV infection.
Policies to address HIV/AIDS Among Africa’sElderly – Research on the extent f the problemA recent study from rural Kenya found that HIV caused 17%of deaths among those aged 50 years or older, and that 19%of all deaths attributed to HIV/AIDS occurred amongindividuals aged 50 years or over (Negin et al. 2010). InBotswana, one of the countries most affected by the HIVepidemic, the 2030 projected population pyramid with andwithout HIV/AIDS is shown below:
Policies to Address HIV/AIDS Among Africa’s Elderly – Improve HIV/AIDS CareHIV policies in the elderly need to addressencumbrances to early diagnosis via voluntarytesting in culturally appropriate contexts(ABC-D).More clinical trials among elderly patients, todetermine optimal dosage and responseprofile for anti-retroviral drugs with minimalside effects.Address multiple chronic health needs ofelderly SSAs living with HIV.
Policies to address HIV/AIDS among Africa’s elderly – reduce HIV infection riskAbsolute Poverty (lower Reduce poverty,figure) and gross enrolment Improve educationalratio in educational attainment,institutions. Address gender inequality, Reduce perinatal spread Improve access to health education on HIIV AIDS, Address HIV/AIDS misconceptions Encourage circumcision Address intravenous drug use Promote condom use.
Policies to Address HIV/AIDS Among Africa’s Elderly – Social PensionOnly 6 of 47 SSA nations currently operate stateprovided non-contributory regular cash transfer toolder citizens.Such support is needed in SSA because older peopleare often disproportionately affected by poverty andthe majority of older people have no regular income.In addition to alleviating poverty for older people,social pensions have intergenerational effects as theystimulate school enrolment and continuation andimprove nutrition for the younger generation beingcared for by Africa’s elderly (Kakawani and Abbarao 2005).
Policies to Address HIV/AIDS Among Africa’s Elderly – Healthy Ageing ProgramsHealthy ageing is the process of optimisingopportunities for health, participation, and securityin order to enhance quality of life as people age.Currently, very few healthy aging initiatives exist inAfrica.Healthy ageing by itself may increase risky sexualactivity if it is not complemented by tailored healtheducation programs. Mass health educationmessages targeted at elderly cohorts discouragingconcurrent sexual partners - “zero grazing” - andadvocating for protected casual sex are importantbehavioural change strategies to complement healthyageing initiatives.
Policies to Address HIV/AIDS Among SSA’s elderly – Stigma Reduction Surveys and Policies Perceived Stigma Internalised shame1.I am accused by others for being the 1. I am punished by evilspreader of AIDS in the community 2. My life is tainted2. People gossip about my HIV status 3. I am angry with myself for3. People look down on me getting HIV4. The society isolates me 4. I am a disgrace to society5. I feel discriminated by health 5. My life is filled with shameworkers 6. I feel guilty for being the source6. I feel my life in this society is lonely of disruption in the family7. I worry about how other kids treat 7. I feel my life is worthlessmy children in school as a result ofmy HIV 8. I feel my reputation is lost8. I worry about how others will treat 9. If possible I want to conceal mymy family members as a result of my HIV status for lifeHIV
Policies to Address HIV/AIDS Among Africa’s Elderly – End-of-Life CareDepending on the prevalence of HIV infection, thenumber of people who require end-of-life care everyyear in SSA varies from 0.3% – 1%.Over a third of all HIV+ve patients studied in fiveSSA nations were dissatisfied with the quality ofpalliative care provided. Most elderly people studiedand experienced stigma and severe financial stress inrelation to payment for palliative treatments(Sepulveda et al. 2003).Policies for improved provision of pain managementservices are urgently required.
Successful Program for AddressingEarly Diagnosis of HIV Expanded HIV testing and treatment: provider- initiated voluntary testing of elderly Africans for HIV is of little benefit if it is not complemented by effective, accessible and affordable treatment. Botswana fulfilled these pre- requisites in 2004. In 2004, Botswana introduced an opt-out “routine HIV testing and counselling.” Incidence among adults 15–49yo declined, from 3.5% in 2004 to 2.4% in 2007 (Stover et al, 2008) Over 75% of Botswanians aged over 50 years visit a public health facility at least once a year. Sixty-four year old President Mogae had his blood drawn for an HIV test. This program is the most successful model for HIV testing among the elderly in Africa so far.
HIV Prevention ProgrammesSoul City: Commenced in 1992, Soul City is a televisiondocumentary and mass media intervention which aims toprevent HIV by increasing knowledge, improving riskperception, changing sexual behaviours, and questioningpotentially harmful social norms. Some of the episodesare focussed on elderly HIV risk prevention.The overall goal of the campaign is to reduce new HIVinfections in South Africa by 10% by 2011. By mid-2011,there were 5.38 million infections among the populationof 50 million, down from a UN-estimated figure of 5.6million in 2009.In 2009, the Soul City One Love campaign reached 25% ofpopulation aged 50 and over. Evaluation of the One Lovein terms of safer sex practices was positive, althoughconcurrent partnerships actually increased amongviewers.
Should Circumcision be Promoted as HIVPrevention Strategy Among Elderly SSA Males?Recent studies have shown that circumcision reducesinfection rates by 50 to 60% among heterosexualAfrican men aged 18-35 years. Mathematical modelshave predicted that one new HIV infection could beaverted for every 5 to 15 men who are newlycircumcised.“Countries with high prevalence, generalizedheterosexual HIV epidemics that currently have lowrates of male circumcision consider urgently scaling upaccess to male circumcision services.”- WHO, 2007.About 60% of African men are already circumcised,but in Southern Africa (the region worst affected byHIV) the circumcision rate is less than 20%.
Should circumcision be promoted as HIVprevention strategy among elderly SSA males?
Key Components of Effective HIV/AIDS Policies & Programs in SSA Strong local ownership and control over decision making; Evolution of programmes over time, allowing for experiences to inform decisions; Facilitation, not control, from outside, especially with volunteers, and Recognition of established or new leadership; and functional links to all levels of community resources, including government social services. Improve income generating activities, including involving small grants, or small loans (microcredits). Partner with faith-based initiatives to reduce stigma.– Economic Commission for Africa, 2005.
Lessons from Asia-Pacific region - LeadershipAustralia provides funding for “Without leadership, thethe Asia Pacific Leadership fight against AIDS becomes sporadic, reactive, withoutForum provides funding for focus, lacking resources,the design & implementation and will eventually loseof HIV strategies. steam. In most countries, national leadership spellsSince 2006, Australia has had the difference between thean Ambassador for HIV. This slowing down and therole encourages political, acceleration of the spreadbusiness and community of AIDS.”leadership on global and - H E Dr Susilo Bambangregional HIV issues, and Yudhoyono,drives debate and advocacy President of the Republic of Indonesia, Bali HIVon key policy or programming Conference, 2009.areas.
Lessons from Asia-Pacific Region – Civil SocietyIn the Asia Pacific, Australia supports and helpsstrengthen regional civil society organisations suchas the Asia-Pacific Network of People Living withHIV/AIDS (APN+) and the Coalition of Asia PacificRegional Networks on HIV/AIDS (7 Sisters).Australia also supports the Asia regional hub of theInternational HIV/AIDS Alliance in Phnom Penh.The Alliance helps develop civil societyorganisations’ skills in advocacy, leadership andfinancial management. With more knowledge andconfidence, these organisations can be a real voicefor civil society at the regional level.
Lessons from Asia-Pacific Region – Improving Care and TreatmentSince 2006, Australia has “… Prevention,funded Clinton Health treatment, care andAccess Initiative projects support for thosein China, Vietnam, infected and affected by HIV/AIDS are mutuallyIndonesia and Papua New reinforcing elements ofGuinea. The aim is to an effective responseremove obstacles to people and must be integratedreceiving antiretroviral in a comprehensivetherapy by improving the approach to combat thedistribution and access to pandemic.”anti-retroviral drugs. -UNGASS Political Declaration on HIV/AIDS, 2006
- Lessons from Asia-Pacific Region - Advocating for Human RightsAusAID has provided “By repealing these punitive HIV laws andfunding for the making what is “hidden”Global Commission no longer “hidden” andon HIV and the Law. by attacking discrimination,The Commission is harassment, black mailinvestigating how and sexual abuse, vulnerable groups will bepunitive laws and able to access services farhuman rights more effectively than atviolations can block present”. - Dame Carol Kidu, Minister foreffective HIV Community Development, Papua New Guinearesponses.
Lessons from Asia-Pacific Region – Alleviating Socio-Economic Impact“HIV deepens poverty, exacerbates hunger andcontributes to higher rates of TB and otherinfectious diseases.” Ban Kim Moon, UN SG,2011.The World Food Program was one of the firstagencies to provide nutritional support to peopleon antiretroviral therapy. Since 2001, AusAIDhas been funding the World Food Program inZimbabwe – a major component of thisoperation is support and food assistance topeople living with HIV and their carers.
Lessons from Asia-Pacific Region – Developing Capacity for Research and SustainabilityAustralia has built improved monitoring andsurveillance into many of its HIV programs, includingin Papua New Guinea. Since 2008, Australian fundinghas helped establish over 100 HIV testing sites in PapuaNew Guinea—half of the country’s total public testingsites.In Bangladesh, Bhutan, India, Nepal and Sri Lanka,AusAID has conducted rapid assessments of riskbehaviour and HIV knowledge among people who injectdrugs and their sexual partners.
Conclusion One of the most critical effects of the AIDS epidemic is that it robs the family of its only social security system; economically active members are removed from the equation when they fall ill and die, leaving children and the elderly to fend for themselves. When this situation is complicated by elderly Africans who have themselves contracted HIV and are suffering from its physical, social and mental health effects (as is the case with 5% of Africa’s elderly), the need for multifaceted interventions suggests itself. http://www.youtube.com/watch?v=c7ZXh3WFMMc