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When assessing the impact of the HIV/AIDS epidemic upon the world’s population, older people are often overlooked. HIV prevention measures rarely target the older generation, despite the fact that many older people are sexually active and therefore still at risk of being exposed to HIV. As antiretroviral drugs extend life expectancy, the number of HIV infected older people is increasing.

The epidemic is also affecting older people who are not infected with HIV. With the younger generations facing the full impact of the disease, older people are increasingly having to care for their sick children. The caring for AIDS orphans is also a responsibility that tends to fall to grandparents.

These are just some of the challenges that have been presented to older people as a result of the HIV/AIDS epidemic. The main issues are as follows:

• The number of older people living with HIV/AIDS


A grandmother with her grandchildren orphaned by AIDS

• Older people and the risk of HIV infection
• Older people and HIV testing
• Older people and HIV treatment
• Older people and HIV illness progression
• Older people and HIV prevention
• Older people and stigma
• Older people as carers
• Older people, poverty and HIV/AIDS
  

The number of older people living with HIV/AIDS

The Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates that around 2.8 million adults aged 50 years and older are living with HIV, representing 7 percent of all cases.¹ Until recently, the term ‘adult’ in reports by UNAIDS referred only to those up to the age of 49. This definition changed in May 2006, since when all people aged over 15 have been included in the global statistics. UNAIDS explained their decision as follows:

"...it is now evident that a substantial proportion of people living with HIV are 50 years and older, as shown in age distributions of HIV and AIDS case reports, community studies and population-based surveys".

In general older people are variously defined as those over 50, over 60, or over 65. However, definitions vary depending on culture, local life expectancy and people’s own perceptions of age. Those in their fifties are not generally considered to be ‘old’ in high-income countries, where accessible healthcare and a good diet promote a longer life.

It is estimated that by 2015, half of the 1 million Americans living with HIV will be older than 50.

In the USA, 15% of all new reported HIV diagnoses occur among people over the age of 50, with a quarter of these among the over 60’s.² It is estimated that by 2015, half of the 1 million Americans living with HIV will be older than 50.³ In the UK, the Health Protection Agency reported that almost 4,000 HIV-infected people who were accessing care in 2006 were aged 55 years or over.⁴

Data from low-income countries on this subject is fairly patchy. HIV/AIDS surveillance is commonly conducted in antenatal clinics in low-income countries, largely because many people have little other direct contact with medical services. Data from antenatal clinics doesn’t provide information about people who are above child-bearing age. Instead estimates must be based on household surveys and voluntary HIV testing and counselling (VCT) services.

Analysis of infection data collected from VCT centres in Uganda between 1999 and 2002 found that 4.6% of those who presented at the centres were older people. Of these, 20% tested HIV positive (23.9% of women and 18% of men).⁵ South Africa's national household HIV survey in 2005 found a prevalence of 10.8% among people aged 50-54, 4.5% among those aged 55-59, and 3.9% among those aged 60 or over.⁶

With the advent of Highly Active Antiretroviral Therapy (HAART), more people are living longer with HIV, particularly in high-income countries where antiretroviral (ARV) drugs, treatment for opportunistic infections, and excellent palliative care are widely accessible.

Older people and the risk of HIV infection

As with young adults, the majority of HIV infections among older people occur through unprotected heterosexual sex.⁷ As women pass childbearing age they are less likely to use a condom during sex, as it is not required for contraceptive purposes. After the menopause a natural thinning of the vaginal walls occurs in many women and lubrication reduces causing an increased risk of tearing during intercourse and making older women more susceptible to HIV infection.

Many older people become intimate with a new partner later in life after a divorce or the loss of a partner. The development of drugs such as Viagra means that some older men who have been unable to have sex become sexually active again. For many older people the idea that they may be at risk of contracting HIV in later life is an alien one because prevention information is targeted almost exclusively at younger people and awareness of risk factors amongst older people is low. Older people are therefore less likely to take measures to reduce their risk of contracting HIV when having sex with a new partner.

The older generation are often more likely than younger people to experience poor health and to require medical attention. In some low-income countries blood screening for HIV may be unreliable and older people, who are more commonly the recipients of donated blood, can face an increased risk of contracting the virus through contaminated blood.

Older people and HIV testing

The assumption that older people are not sexually active often prevents an early diagnosis of HIV. Older people may be reluctant to talk to doctors about their sex lives and medical professionals may be reluctant to ask the right questions. This often results in the overlooking of possibilities that an older person might have come into contact with HIV, and HIV testing will not be thought necessary. The lack of understanding of the virus amongst older people in high-income countries, such as the UK, and in low-income countries, makes them less likely to come forward for testing, as they do not believe that they could be at risk of contracting the virus.

Often the idea that an older patient might have contracted HIV will be the last possibility investigated when all other options have been exhausted. The symptoms that an older person with HIV presents with - such as fatigue, weight loss, poor memory, skin rashes and swollen lymph nodes - can be seen in many other illnesses typically associated with ageing, resulting in frequent misdiagnosis.

Older people and HIV treatment

Antiretroviral drugs, which are used to suppress HIV and delay its progression to AIDS, are rarely tested on older people. One large European study found that those over the age of 50 responded better to treatment than younger people with regards to reducing the amount of HIV in the body.⁸ However, older individuals also tended to have poorer immune system responses to the drugs. This means that older people receiving treatment may be more at risk of HIV disease progression and developing opportunistic infections.

The side effects of antiretroviral drugs are not thought to be any worse among older people. However, some signs of ageing could resemble certain side effects that people taking antiretrovirals might suffer from. For example, when people get older they might be more susceptible to increased fat in the abdomen, which could look similar to the changes that are caused by lipodystrophy (changes in body fat that are seen in people taking antiretroviral drugs).

There are also problems of drug interferences and interactions, which doctors need to be aware of when prescribing antiretroviral drugs for older people with HIV. When finding a suitable drug combination, doctors have to take into account other medications that patients may be taking for age-related illnesses such as heart disease, depression, high blood pressure, Alzheimer’s disease and arthritis.

Discriminatory attitudes towards older people are common and can affect the treatment they receive. Older family members who are no longer economically productive, especially those who require care, sometimes tend to be viewed by their families – and sometimes by themselves - as a burden, nearing the end of their useful lives and therefore not worth expending resources on. In low-income countries, impoverished families with more than one HIV positive family member may find themselves having to make difficult decisions about whom to buy drugs for.

Older people and HIV illness progression

Without antiretroviral drugs, older people are likely to develop AIDS related illnesses faster than younger people because their immune systems are already weaker due to old age. However, now that antiretroviral drugs are available in some parts of the world, those older people taking them have strengthened immune systems and tend to live as long as younger people taking antiretroviral drugs.

A lot of research is currently being carried out in order to determine the relationship between health problems and HIV in older people. Cancer, diabetes, heart disease, dementia etc. are all common health problems that people face in old age. However, the extent to which these may be more prevalent among older people with HIV is still to be determined.

Whatever the outcome of the research, exercising regularly, avoiding smoking, eating lots of fruit and vegetables and only drinking moderate amounts of alcohol, are all things that people can do to reduce their risk of acquiring health problems in old age. These things can also maintain a healthier and longer life when living with HIV.

Older people and HIV prevention

In most countries across the world there are very few prevention strategies aimed at older people. Educating older people as to the routes of HIV transmission would enable them to alter their behaviour and reduce their risk of contracting HIV. This may be as simple as using a condom, or in some countries this may involve making informed choices about traditional practices, such as wife inheritance or sexual cleansing – a ritual which demands that a widow have sex with another man in order to purge the spirit of her dead husband.⁹

Older people may lack the knowledge about the routes of HIV transmission necessary to protect themselves from HIV infection. They also may lack the education to ensure the best healthcare options for themselves and their families, especially in low-income countries where large numbers of older people turn first to traditional healers to fight ill health.¹⁰ When caring for themselves or sick or dying children and grandchildren, this may not be the best course of action if antiretroviral drugs are immediately available.

Older people are generally respected by the younger generation in most parts of the world and could pass on knowledge of HIV/AIDS. They could therefore potentially help in reducing the spread of HIV worldwide, if they had the sufficient education themselves.

The US has already begun to realise the importance of educating older people about HIV/AIDS. In Florida there is a higher than average number of HIV infections among older people, as it is the most popular retirement destination in the US. The Senior HIV Intervention Program (SHIP) has been set up to train older people in providing HIV/AIDS information to their peers. ¹¹ Educators visit retirement homes and assisted living centres, in order to highlight the risk of HIV infection among older people.

Older people and stigma

The stigma that surrounds HIV and AIDS in all countries remains a huge barrier to overcoming the pandemic. Stigma commonly arises from ignorance: people who do not know how the virus is transmitted may be wary of “catching” it. Some may also associate HIV with promiscuity, drug addiction or other types of behaviour that commonly carry their own stigmas.

Furthermore, older people are often stigmatised in many societies before HIV is even considered – they may be seen as non-economically productive community members who consume resources without contributing. Older people who are infected with HIV will thus have a double burden.

The impact of stigma on older people may take other forms. In countries where traditional medicines are popular and witchcraft is given credence, older people may suffer terribly from the ignorance within their own communities. Some older people who have lost children and grandchildren to the pandemic have then been accused of witchcraft and physically abused or excluded.¹²

Older people as carers

• 60% of orphaned children in Namibia, South Africa and Zimbabwe are living with their grandparents¹³
• About 30% of all households in sub-Saharan Africa are headed by an older person¹⁴
• 56% of carers for orphans and vulnerable children in Namibia are more than 60 years old¹⁵

The vast numbers of deaths from AIDS in low-income countries have dramatically changed societies, in some places almost wiping out the middle generation and leaving older people and the very young to take care of each other. In addition to caring for grandchildren, older people in their 60’s and 70’s are frequently left nursing dependents through the terminal stage of illness and must contend with the trauma of burying their children.

Older people left caring for sick offspring or orphaned children face the burden of providing financial, emotional and psychological support at a time when they would usually be expecting to receive more support as their energy levels drop with older age. Due to the amount of time spent caring for dependents, older people may become isolated from their peers as they no longer have the time to dedicate to their social networks that need to be fostered to prevent isolation and loneliness.¹⁶

Older people, poverty and HIV/AIDS

Older people are particularly vulnerable to poverty as they retire, find themselves unable to work or unable to find employment and a regular income. In many low-income countries there is no pension provision and older people must scrape by in whatever way they can. The HIV/AIDS pandemic exacerbates the poverty that many older people are living in. Energy that might otherwise have been dedicated to income-generating activities is diverted to ensuring children attend school or providing around the clock healthcare.

When children with AIDS die, older people must find both the money for burials and the strength to care for those left behind, many of whom they know are sick and will also die. At this extremely stressful time the vast majority of older people are offered no support, either financially, physically or emotionally.

As older people focus their resources on caring for their children and grandchildren they may neglect themselves, often going without in order to provide for others. This may result in malnutrition and rapidly failing health. Falling ill affects the quality of care that older people can provide.

The future

There are many things that can be done to improve the position of older people within the pandemic:

Research – As the number of older people with HIV is growing, clinical trials should be tailored to meet their needs. More research should be done into drug interactions, particularly those drugs that are commonly taken in older age.

Older people should be included in figures when mapping the epidemiology and prevalence of HIV and AIDS across the world.

Research into the unique challenges faced by older people with HIV is needed so as to enable service providers to design their programmes to better suit the over 50’s.

Education – Awareness raising programmes need to target doctors and healthcare professionals to try to break down the age stereotyping that prevents many older people benefiting from early diagnosis.

Prevention programmes need to be launched that target older people to ensure that they are aware of the routes of transmission and can access condoms, clean needles and other resources that would allow them to reduce their risk of contracting HIV.

Training older people to be ‘listeners’ or counsellors, as a project in Mozambique has done,¹⁷ allows them to help in eradicating the stigma within society and provides them with support in their role as caregivers to orphaned grandchildren or dying children.

Policy – Governments and civil society must recognise the part older people play in caring for people living with HIV and AIDS.

In South Africa non-contributory pension programmes reach large numbers of poor older people (1.9 million) at a relatively low cost (1.4 % GDP).¹⁸ Providing older people with a pension helps them to care for those dependent on them, provide food and ensure that children attend school. Aid budgets should include money for pensions for the poorest older people in the world. Older carers would then stand a much better chance of giving their dependents a good start in life.

Conclusion

The HIV epidemic means that older people are finding new importance as carers of children and sick adults and as wage earners – even though they may themselves be experiencing the health problems associated with old age. In low-income countries, older people are becoming increasingly valuable to both the family and society.

Attitudes towards the elderly need to change and older people need to be given the rights and respect accorded to their children. Assumptions about older people need to be re-examined and HIV prevention messages need to realise that older people do have sex and take drugs. They need to know that they may be at risk of infection and they need to know how to protect themselves. The global fight against AIDS must not be allowed to overlook older people – HIV doesn’t respect age and it is not only a problem for the young.

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