Nicole Stoller, Owusu Barnabas, Naa Ashiley Vanderpuye-Donton
International Health Care Clinic / West Africa AIDS Foundation, Accra, Ghana
Corresponding author: Naa Ashiley Vanderpuye-Donton
Plot 650, Haatso Ecomog Ave, Haatso
E-mail addresses of authors:
Keywords: age 50 years plus, HIV, stigma, viral suppression, disclosure, Africa
Introduction: Since the advent of life-prolonging antiretroviral therapy, the number of elderly people living with HIV has risen steadily to 7.5 million worldwide. However, HIV data of the 50 years plus age group are still relatively poor in many countries, including sub-Saharan Africa. The goal of this study was to provide a set of baseline characteristics of people living with HIV aged 50 years plus in Ghana.
Methods: We performed a retrospective analysis of the routinely collected patient data from an HIV outpatient clinic in Accra. Demographic, behavioural and clinical characteristics of HIV-infected individuals (N = 282) aged 50 years plus enrolled in care from January 2015 to June 2019 were selected. Descriptive and inferential statistics were used for analysis.
Results: The median age was 56 years, 57% (162/282) were female. At 51.4% (113/220), half of the patients were married. Secondary level education had been finished by 34% (64/188). The majority of 93.8% (225/240) were Christians. Current sexual activity was reported by 44.2% (111/251) and occasional use of condoms by 67.1% (96/143). More than two thirds (184/264, 69.7%) had WHO clinical stage I or II. Nearly all patients of the sample, 97.3% (249/256) were on antiretroviral treatment. Good adherence to treatment was reported by 70.2% (172/245). The main reason for missing dose(s) was pill leakage (91/164, 55.5%). Viral suppression with less than 1000 copies/ml was achieved by 63.6% (89/140). Almost three out of four HIV-infected individuals (191/260, 73.5%) did not disclose their status.
Conclusions: In our sample a very high proportion of patients received antiretroviral treatment, more than two-thirds reported good adherence to medication and nearly two-thirds had achieved viral suppression. However, high non-disclosure rates indicate that stigma and discrimination seem to be one of the greatest challenges for people with HIV over the age of 50.
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 HIV-infected people worldwide aged 50 and over (3,4). More than 4 million of PLHIV 50 years plus live in sub-Saharan Africa (4), a figure that is expected to rise in the coming years (5). However, reporting on HIV data ended historically 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 & Mills (7) found that people aged 50 years and over show similar HIV risk behaviour to younger age groups, but paired with poor HIV awareness and a low perception of their own risk of acquiring HIV.
The higher age of PLHIV leads to various physical challenges that can affect the quality and quantity of life, including general age-related comorbidities such as cardiovascular disease or cancer, and specific injuries from HIV infections or consequences from 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 stigmatisation 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, such 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 data (13), specific information about Ghanaian PLHIV 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 HIV-infected population but also to integrate the 50 years plus age group into HIV monitoring and reporting systems (2).
The main goal of this study is therefore to provide a set of baseline characteristics of older people living with HIV by analysing routinely collected patient data. As a minor goal, the study should identify, whether the analysed characteristics reveal gender disparities. As more specific insights into the age group 50 years plus are gained, healthcare facilities can further develop patient-oriented and gender-specific services to meet the needs of their patients.
The study was conducted in an HIV clinic in Accra, Ghana, a lower middle-income country in West Africa. The community out-patients clinic is open to the general public with a focus on infectious diseases. It has been providing medical care and support for PLHIV since 1999. In addition to other services, the clinic also provides counselling for patients on issues such as disclosure of HIV status or therapy adherence.
Study design and sample
We carried out a retrospective analysis of routinely collected patient data from electronic medical records. The sample included all HIV-infected patients aged 50 years or older who were admitted into care from January 2015 to June 2019.
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 of viral load results, blood samples were taken in-house and sent to a teaching hospital in Accra.
We described frequencies of the selected variables, stratified by gender. To compare the categorical variables between women and men we used Pearson’s chi-square test, resp. Fisher’s exact test when assumptions of chi-square test were not reached. For metric data we used Mann-Whitney-U test. An alpha level of .05 was assumed for statistical significance. Cramer´s V was used as effect size for chi-square test, with values of .10 for small, values of .30 for medium and values of .50 for large effects (15). Statistical analysis was performed using Microsoft Office Excel 2016 and IBM® SPSS Statistics, Version 25.
The data analysis of our research originated from a clinic-internal project for quality improvement, for which ethical approval was not requested. The retrospective analysis was based on routine data without actual physical involvement of clients.
Due to the retrospectivity, consents from the patients were not available.
All data were de-identified prior to analysis. The anonymity of the sample was guaranteed, and no conclusions could be drawn about the patient identity.
We identified 286 PLHIV aged 50 years or older enrolled in the above-mentioned HIV health clinic between January 2015 and June 2019. Four cases were excluded due to 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%). The association between marital status and gender was significant with a moderate effect (p < .001, V = .41). Men were more likely than women to be married (67/91, 73.6% vs. 46/129, 35.7%). The majority were Christians (225/240, 93.8%), 5% (12/240) were Muslims. The association between education and gender was significant with a moderate effect (p < .001, V = .33). Men were more likely than women to have finished secondary level education (39/73, 53.4% vs. 25/115, 21.7%). All results of demographic characteristics are shown in Table 1.
Table 1. Demographic characteristics of people living with HIV aged 50 years plus at a Ghanaian HIV-clinic, 2015 – 2019
|finished secondary||64||(34,0)||25||(21,7)||39||(53,4)||< .001§***|
|not finished secondary||124||(66,0)||90||(78,3)||34||(46,6)|
|† Mann-Whitney-U test, ‡ Fisher´s exact test, § Pearson’s chi-square test. All values are n (%) or median (IQR).|
Current sexual activity (not further specified) was confirmed by 44.2% (111/251). The association between sexual activity and gender was significant with a moderate effect (p < .001, V = .42). Men were more likely than women to report sexual activity (72/104, 69.2% vs. 39/147, 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). Among the latest responses in case of non-adherence, the most frequently cited reason for missing ART dose(s) was Ran out of pills (91/164, 55.5%). Nearly three quarters of the patients, 73.5% (191/260), have not disclosed their HIV status to family, friends or sexual partner. The association between disclosure and gender was significant with a small effect (p < 0.001, V = .25). Women were more likely than men not to have disclosed their HIV status (126/152, 82.9% vs. 65/108, 60.2%). All results of behavioural characteristics are shown in Table 2.
Table 2. Behavioural characteristics of people living with HIV aged 50 years plus at a Ghanaian HIV-clinic, 2015 – 2019
|sexually active||111||(44,2)||39||(26,5)||72||(69,2)||< .001†***|
|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)||.925†|
|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)|
|Reasons for missing dose||164||100||64|
|unable to pay||11||(6,7)||6||(6,0)||5||(7,8)||.840†|
|ran out of pills||91||(55,5)||58||(58,0)||33||(51,6)|
|Disclosure of HIV status||260||152||108|
|† Pearson’s chi-square test. All values are n (%). ART: Antiretroviral therapy|
Almost half of the patient group had WHO clinical stage I (118/264, 44.7%), 69.7% had stage I or II (184/264). Nearly all patients of the sample 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 3 months. Among them 63.6% (89/140) were virally suppressed with < 1000 copies/mL. The association between viral suppression and gender was significant with a small effect (p < 0.05, V = .20). Women were more likely than men to have achieved viral suppression (58/81, 71.6% vs. 31/59, 52.3%). All results of clinical characteristics are shown in Table 3.
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. 3 months)||140||81||59|
|< 1000 copies/mL||89||(63,6)||58||(71,6)||31||(52,5)||< .05†*|
|≥ 1000 copies/mL||51||(36,4)||23||(28,4)||28||(47,5)|
|† Pearson’s chi-square test. ‡ Fisher’s exact test. All values are n (%). ART: Antiretroviral therapy|
Our study sample of 282 PLHIV aged 50 years plus showed a high proportion of sexually active men (69.2%). This is comparable to findings of other studies in sub-Saharan Africa. Country reports from this area have shown that 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 having 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, more 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 (9,18).
More 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 did not disclose their HIV status, neither to family or friends nor to current sexual partners. These results, which are even more significant for women, show the great difficulties PLHIV in Ghana face in openly talking about their status. Unlike our findings Obermeyer et al. (22) reported disclosure rates of over 74% among HIV-infected adults in sub-Sahara 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 study (23) 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 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 HIV-infected individuals (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). 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 a 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 in 140 cases. Viral suppression with < 1000 copies/mL was achieved for 63.6%. This result for elderly HIV-infected individuals is not yet reaching the third UN target of 90% viral suppression, but already much closer to reach the target, compared to the general adult HIV-population in sub-Saharan Africa with 29% of viral suppression (14). The effect of age on the response to ART in this area is not well documented so far (26). However, as mentioned before, PLHIV 50 years plus are an age group with good adherence to treatment. And moreover, several studies with older HIV patients reported poor immunological responses to ART, but similar or even better virological responses of older, 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 were also stated by other researchers and appear to be found in most limited-resource countries (26). However, 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). UNAIDS 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 HIV-infected populations. 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 responding (27).
We performed a retrospective analysis of routinely collected patient data from a HIV outpatient clinic in Accra, Ghana. The main goal was to provide a set of baseline characteristics of older people living with HIV by analyzing routinely collected patient data. Our results showed that a very high proportion 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 indicate that stigma and discrimination seem to be one of the biggest challenges for PLHIV 50 years plus.
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 becomes 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.
The other authors have no competing interests to declare.
NA conceived the study and contributed to interpretation of results. OB extracted the data and contributed to interpretation of results. NS analysed the data and drafted the manuscript. All authors reviewed and approved the final manuscript.
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.
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