Nicole Stoller1,2 , Barnabas Owusu 1 and Naa A. Vanderpuye-Donton1
1West Africa AIDS Foundation / International Health Care Clinic, Plot 650, Haatso Ecomog Ave, Haatso, Accra, Ghana
2University of Applied Sciences and Arts Northwestern Switzerland, School of Applied Psychology, Riggenbachstrasse 16, 4600 Olten, Switzerland
Corresponding author: Nicole Stoller
Conflict of interest: None declared
Objective: Data on HIV amongst the age group 50 years and above are relatively poor in many countries, including
sub-Saharan Africa. The main goal of this study was to provide a set of baseline characteristics of older people liv
ing with HIV (PLHIV). Further, the study sought to identify, whether the analysed characteristics revealed gender
Methods: A retrospective analysis of patient data at the International Health Care Center, a private ART-accredited
health facility in Ghana was performed. Demographic, behavioural and clinical characteristics of 282 PLHIV aged
50 years or older at their most recent consultation between 2015 and 2019 were selected. Descriptive and inferential
statistics were used for analysis.
Results: Sexual activity was confirmed by 44.2%, more frequently by men (χ2 (1, N = 251) = 45.02, p < .001, V =
.42). Nearly all patients (97.3%) were on antiretroviral treatment, 70.2% adhered well. Viral suppression with <1000
copies/ml was achieved by 63.6%, more frequently by women (χ2 (1, N = 140) = 5.36, p = .021, V = .20). Non-dis
closure of HIV status was reported by 73.5%, with more women not having disclosed (χ2 (1, N = 260) = 16.70, p <
.001, V = .25).
Conclusions: In a geographical area where specific HIV-data are sparse, further research is needed to learn more
about the situations and needs of PLHIV aged 50 years plus. Additionally, the finding of high non-disclosure rates
could indicate that stigma and discrimination are amongst one of the biggest challenges for this age group.
Keywords: age 50 years plus, HIV, stigma, disclosure, Africa
Funding: None Declared
The longevity of people living with HIV (PLHIV) has risen since the advent of life-prolonging antiretroviral medication.1,2 The number of older PLHIV has increased steadily in recent years and currently stands at 7.5 million
people diagnosed with HIV worldwide aged 50 and over.3,4 More than 4 million PLHIV 50 years plus live in sub-Saharan Africa4, a figure that is expected to rise in the coming years.5 However, reporting on HIV data his torically ends at the age of 49, and information on older people living with HIV/AIDS is still relatively poor.1,2
While HIV prevention, intervention programmes and sexuality studies in sub-Saharan Africa have focused mainly on the younger adult population aged 15-49, little has been done to understand the sexual behaviour of the population 50 years plus.6
Bendavid, Ford & Mills7 found that people aged 50 years and over show similar HIV risk behaviour as younger age groups, but paired with poor HIV awareness and low perception of their own risk of acquiring HIV. Ageing with HIV could lead to various physical challenges, including general age-related comorbidities such as cardiovascular disease or cancer and organ system injuries as a result of HIV infections or the toxicity of antiretroviral treatment (ART).8 Regarding the psychosocial challenges, the impact of stigma and discrimination can be devastating for older PLHIV in sub-Saharan Africa, as they face fears of rejection and exclusion from society.9
Moreover, the perceived lack of confidentiality of health workers increases the concerns of PLHIV about stigmatization or involuntary disclosure of their HIV status.10,11 In Ghana, where this analysis was carried out, HIV prevalence in the general population is 1.7%, with prevalence rates in the key population disproportionately high, such2 as female sex workers (6.9 %) and men who have sex with men (18 %).3,12 While Ghana is also confronted with a paucity of accurate HIV data13, specific information about Ghanaian PLHIV belonging to the age group 50 years plus are also sparse. According to the Ghana National AIDS Control Program, there are no accurate data on adherence to ART or on the number of patients on
ART with achieved viral suppression.13 This data is also necessary to assess the current status of the UNAIDS 90-
90-90 goals, i.e. by 2020, 90% of people living with HIV know their status, 90% who know their status receive sustained treatment and 90% of those on treatment are virally suppressed.14 Further efforts are needed not only to improve baseline data for the general population diagnosed with HIV but also to integrate the 50 years plus age group into HIV monitoring and reporting systems.2
The main objective of this study was therefore to identify a set of baseline characteristics of older people with HIV. As a secondary objective, the study sought to determine whether the characteristics analysed revealed gender disparities.
The study was conducted at the International Health Care Center, a private ART accredited health facility in Accra, Ghana, a lower middle-income country in West Africa. The community out-patients clinic is one opened to the general public with a focus on infectious diseases. It has been providing medical care and support to PLHIV since HIV services are fully integrated into the services of the clinic and in addition to other services, the clinic provides counselling for patients on issues such as disclosure of HIV status and therapy adherence.
Study design and sample
A retrospective analysis of routinely collected patient data from electronic medical records was carried out. PLHIV were eligible if they were 50 years old or older at their most recent medical consultation at the facility between January 2015 and June 2019. Both the initial admission and follow-up appointments were considered medical consultations.
The study was a retrospective data analysis of routinely collected patient information using an electronic medical records system. Data was de-identified before to analysis. The anonymity of the sample was guaranteed, and no conclusions could be drawn about patient identity.
Data source and variables
Routinely collected patient data were exported from the electronic clinical information system. The data export was programmed to obtain the latest available data for each variable. The selected variables were divided into demographic, behavioural and clinical characteristics. Answers like unknown or not applicable were treated as missing data. The variables had been recorded electronically by trained physicians, nurses and laboratory technicians. For obtaining viral load results, blood samples were taken in-house and sent to a teaching hospital in Accra for analysis, and results were sent back to the health facility.
We described frequencies of the selected variables, stratified by gender. To test the associations between gender and the nominal variables, we used Pearson’s chi-square test (i.e., for marital status, educational level, sexual activity, disclosure, patient on ART, viral load), resp. Fisher’s exact test if the assumptions of the chi-square test were not reached (i.e., for religion). To compare the continuous and ordinal variables between women and men, we used the non-parametric Mann-Whitney test (i.e., for age, age groups, condom use, adherence to ART, WHO clinical stage). We used an alpha level of 0.05 for all statistical tests. After the chi-square test detected significant associations, we evaluated the strength of the association using Cramer’s V. The effect size Cramer’s V can reach its maximum of one, with values of .10 for small, .30 for medium and .50 for large effects.15 Statistical analysis was performed using Microsoft Office Excel 2016 and IBM® SPSS Statistics, Version 25.
We identified 286 PLHIV aged 50 years or older at their most recent medical consultation at the International
Health Care Center between January 2015 and June 2019. Four cases were excluded due to a lack of relevant data. A total of N= 282 cases was finally included in the study. Since complete medical records were not available for all cases, the actual numbers for each variable are shown below. All gender-specific results can be seen in Tables 1 – 3.
The sample of patients consisted of 57% women (162/282) and 43% men (120/282). The age of the patients ranged from 50 to 91 years with a median age of 56(IQR, 52-61). The majority, 70.6% (199/282) were in the 50-59 age group. More than half of the patients were married (113/220, 51.4%). Men were more likely than women to be married or widowed (75.8% vs. 60.5%). The association between marital status and gender was significant with a moderate effect, χ2 (1, N = 220) = 5.68, p = .020, V = .16. The majority of the sample group were Christians (225/240, 93.8%), 5% (12/240) were Muslims. Men were more likely than women to have finished secondary level education (53.4% vs. 21.7%). The association between education and gender was significant with a moderate effect, χ2 (1, N = 188) = 19.97, p < .001, V =.33. All results of demographic characteristics are shown in Table 1.
Current sexual activity (not further specified) was confirmed by 44.2% and the frequencies differed significantly between gender, χ2 (1, N = 251) = 45.02, p < .001. The effect was moderate with V = .42. Men were more likely than women to report sexual activity (69.2% vs.26.5%). Occasional use of condoms (sometimes) was reported by 67.1% (96/143) of the patient group. Good adherence to ART with zero pills missed in the last 3 days was reported by 70.2% (172/245). Nearly three-quarters of the patients, 73.5% (191/260), had not disclosed their HIV status to family, friends or sexual partners. Women were more likely than men not to have disclosed their HIV status (82.9% vs. 60.2%). The relationship between disclosure and gender was significant, however with only a small effect, χ2 (1, N = 260) = 16.70, p < .001, V = .25. All results of behavioural characteristics are shown in Table 2.
Almost half of the patient group had the WHO clinical stage I (118/264, 44.7%). Nearly all patients of the sample group with available data, 97.3% (249/256), were on ART. Viral load test results were available for 140 patients who were on ART for at least 6 months. Among them, 63.6% (89/140) were virally suppressed with < 1000 copies/mL. Women were more likely than men to have achieved viral suppression (71.6% vs. 52.5%). The association between viral suppression and gender was significant with a small effect, χ2 (1, N = 140) = 5.36, p = .022, V = .20. All results of clinical characteristics are shown in Table 3.
Our study sample of 282 PLHIV aged 50 years plus showed a high proportion of sexually active men (69.2%). This is comparable to the findings of other studies in sub-Saharan Africa. Country reports from this area have shown that within the general population about 74%of men aged 50 years and over are sexually active and that the majority of them are engaged in high-risk sexual behaviour, such as having multiple sex partners and not using condoms.6,16 A study from South Africa also revealed the tendency of elderly men to have multiple partners, while women accepted the male promiscuity.17 The study further stated that both genders blame each other for the spreading of HIV/AIDS. Both, elderly men and women, should be more strongly approached for HIV prevention and treatment. Whereas men over 50 years are at risk of infection due to unsafe sexual behaviour, women in the sub-region are also at high risk of acquiring HIV, due to cultural and physical reasons.9 Gender inequality still results in insufficient negotiating power for women in marital relationships. Lack of control over decisions or financial resources can prevent them from gaining access to health facilities for HIV testing or treatment.11 Sexually active women over 50 years of age are at additional risk of HIV infection from hormonal changes.9 A thinner post-menopausal vaginal wall promotes, among other things, tissue injury and thus HIV transmission during sex.9,18More than two-thirds of the patients reported that they adhered well to ART. Other authors have described high adherence to ART in the older population, suggesting that adherence is the key factor for older PLHIV when it comes to better virological responses compared to younger age groups.19,20 However, it should be noted that older people’s adherence to treatment may decrease due to simultaneous suffering from age-related chronic diseases or difficult socio-economic conditions leading to food insecurity or lack of resources to transport them to a clinic.21
Furthermore, we found that a high proportion (73.5%) of women and men living with HIV disclosed their HIV status, neither to family or friends nor to current sexual partners. This result, which is more significant amongst women, showcases the difficulties PLHIV inGhana face openly talking about their status. Unlike our findings, Obermeyer et al.22 reported disclosure rates of over 74% among adults diagnosed with HIV in sub-Saharan Africa, but with strong variations between the countries. The authors found no clear evidence as to whether more men or more women had disclosed their status. Nevertheless, gender differences have been revealed in a study23 in Ethiopia. Regarding reasons for nondisclosure the authors found that men were inclined to report that they didn´t want to reveal infidelity, while women were more likely to report fear of violence or abandonment. Ojikutu et al.24 examined the disclosure behaviour of female PLHIV in Thailand, Brazil and Zambia. The predictors for non-disclosure they identified were HIV stigma at the community level, depression,self-stigma, and older age, with similar findings in all three geographical areas. The authors, therefore, recommended focusing mainly on community interventions to reduce stigmatization and discrimination against PLHIV. 24 In Ghana, the question“Would you buy fresh vegetables from a shopkeeper or vendor if you knew that this person had HIV?” was answered “No” by two out of three people in 2014.12
Table 1. Demographic characteristics of people living with HIV aged 50 years plus at a Ghanaian HIV clinic, 2015 – 2019
|finished secondary level||64(34.0)||25(21.7)||39(53.4)||.000b|
|not finished secondary level||124(66.0)||90(78.3)||34(46.6)|
|aMann-Whitney test, bPearson’s chi-square test, cFisher´s exact test. All values are n (%) or median (IQR).|
Table 2. Behavioural characteristics of people living with HIV aged 50 years plus at a Ghanaian HIV clinic, 2015 – 2019
|Not sexually active||140(55.8)||108(73.5)||32(30.8)|
|Adherence to ART last 3 days||245||145||100|
|0 pill missed||172(70.2)||103(71.0)||69(69.0)||.685b|
|1-2 pills missed||14(5.7)||9(6.2)||5(5.0)|
|3-4 pills missed||11(4.5)||6(4.1)||5(5.0)|
|>5 pills missed||48(19.6)||27(18.6)||21(21.0)|
|Disclosure of HIV status||260||152||108|
|aPearson’s chi-square test, bMann-Whitney test. All values are n (%).|
Table 3. Clinical characteristics of people living with HIV aged 50 years plus at a Ghanaian HIV clinic, 2015 – 2019
|WHO clinical stage||264||155||109|
|Patient on ART||256||150||106|
|Viral load on ART (min. 6 months)||140||81||59|
|< 1000 copies/mL||89(63.6)||58(71.6)||31(52.5)||.022c|
|≥ 1000 copies/mL||51(36.4)||23(28.4)||28(47.5)|
|aMann-Whitney test. bFisher’s exact test. cPearson’s chi-square test. All values are n (%).|
This persistently strong stigma in society makes it difficult for PLHIV to talk about their infection. In order to promote PLHIV disclosure initiatives, supportive and trustworthy framework conditions must be created.25
In 2016, the WHO policy Test-and-Treat was adopted in Ghana, which made all PLHIV eligible for ART regardless of the WHO clinical stages or immunological conditions.13 Analysis of our sample showed almost complete coverage of patients on antiretroviral therapy (97.3%), while the estimated coverage of adult patients in Ghana lies at 35%.12 The high number in our sample may be the result of consistent implementation of the WHO policy in the participating health clinic. This result shows that it is possible to achieve at least one of the UNAIDS 90-90-90 goals at the community level.
In our data, we had results for viral load for 140 cases. Viral suppression, defined as < 1000 copies/mL was achieved for 63.6%. This result amongst our elderly PLHIV, although not at the UN target of 90%, is close to reaching the target, compared to that of the general adult HIV-population in sub-Saharan Africa which stands at 29% for viral suppression.14 The effect of age on the response to ART in this area is so far not well documented.26 However, as mentioned before, the 50 years plus PLHIV age group has been charactered with good adherence to treatment.
Moreover, several studies with older PLHIV on ART re- ported similar or even better virological responses of older groups, compared to younger age groups.19,20 A finding that requires further investigations is the moderate amount of available viral load data. Low availability of viral load results was also stated by other researchers and appears to be found in most limited-resource countries.26 Testing and monitoring of viral load is essential to
enable physicians to make timely and accurate medical decisions about the treatment of their HIV patients.14 UN- AIDS recommends a combination of centralised laboratories and point-of-care tools to provide easy and affordable access to viral load testing for patients in all situations, urban and rural.14
Our study contains some limitations. The sample is based on one outpatient health facility and may not represent other populations diagnosed with HIV. In addition, the method of data extraction from the electronic medical folders leads to some restrictions for statistical evaluation, since the data of a patient case may originate from two or more follow-up appointments in the clinic. Finally, as a general limitation, the accuracy of self-reported answers to questions about sexual activity, condom use or adherence to treatment may be limited due to socially desired responses.27
Nevertheless, in a geographical area where specific HIV data are sparse, further research is needed to learn more about the situations, needs or challenges of the 50 years plus age group. As more differentiated information be- comes available, healthcare institutions can further develop patient-oriented and gender-specific services and optimize medical and psychosocial care and support for this growing HIV population.
A retrospective analysis of routinely collected patient data from an outpatient clinic with integrated HIV services in Accra, Ghana was performed. The main goal was to provide a set of baseline characteristics of older people living with HIV. Our results showed that a very high pro-portion of the sample was on ART, more than two-thirds
reported good treatment adherence and viral suppression was achieved by more than 60%. However, high non-disclosure rates could indicate that stigma and discrimination are amongst key challenges faced by PLHIV in the age group 50 years plus.
We thank Sandra Opokua for her contribution in initial data plausibilization and Nadine Schneider for reviewing the manuscript. We also thank the team of the International Health Care Clinic and West Africa AIDS Foundation for provision of clinical knowledge during the study.
- Brennan-IngMG, MacPhail C, Seeley J, Kureesa M, Miniciellp V, Venter F, et al. Global ageing with HIV: Differences between high- and low-resource settings. Innov Ageing 2017;1:622. doi:10.1093/geroni/igx004.2185
- Mahy M, Autenrieth CS, Stanecki K, Wynd S. In- creasing trends in HIV prevalence among people aged 50 years and older. AIDS 2014; doi:10.1097/QAD.0000000000000479
- UNAIDS DATA 2019. Geneva: UN- AIDS; 2019. http://www.unaids.org/sites/de-fault/files/media_asset/2019-UNAIDS-data_en.pdf. Accessed 21 March 2020.
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- HontelezJAC, Tanser FC, Naidu KK, Pillay D, Bär- nighausen T. The effect of antiretroviral treatment on health care utilization in rural South Africa: A population-based cohort study. PLoS ONE 11(7): e0158015. doi:10.1371/journal.pone.0158015
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- Bendavid E, Ford N, Mills EJ. HIV and Africa’s el- derly: The problems and possibilities. AIDS 2012; doi:10.1097/QAD.0b013e3283558513
- Althoff K, Smit M, Reiss P, Justice AC. HIV and ageing: Improving quantity and quality of life. Curr Opin HIV AIDS 2016; doi:10.1097/COH.0000000000000305
- The Gap Report. Geneva: UNAIDS; 2014. http://files.unaids.org/en/media/unaids/con-tentassets/documents/unaidspublication/2014/UN- AIDS_Gap_report_en.pdf. Accessed 21 March 2020.
- Adjetey V, Obiri-Yeboah D, Dornoo B. Differenti- ated service delivery: A qualitative study of people living with HIV and accessing care in a tertiary fa- cility in Ghana. BMC Health Serv Res 2019;19:1–7. doi:10.1186/s12913-019-3878-7
- Musheke M, Ntalasha H, Gari S, Mckenzie O,Bond
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- Country factsheets GHANA 2018. HIV and AIDS Estimates. Geneva: UNAIDS; 2018.http://aidsinfo.unaids.org/. Accessed 21 March 2020.
- Ali H, Amoyaw F, Baden D, Durand L, BronsonM, Kim A, et Ghana’s HIV epidemic and PEPFAR’s contribution towards epidemic control. Ghana Med J 2019;53:59-62. doi:10.4314/gmj.v53i1.9
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- Wessels JM, Felker AM, Dupont HA, Kaushic C. The relationship between sex hormones, the vaginal microbiomeand immunity in HIV-1 susceptibility in women. Dis Model Mech 2018; doi:10.1242/dmm.035147.
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