HIV among the elderly, a unique emerging Public Health Concern in Zimbabwe

Gogo Chiware (78) (Not her real name), lives with her elderly husband in Hatfield, Harare. She has been living with HIV for the past 15 years and she has been on treatment for 13 years now. However, due to her advanced age, she at times forgets to take her Antiretroviral (ARV) medications.

By Michael Gwarisa

She has a poor support system as her husband who is also living with HIV, is now experiencing dementia and this compounds Gogo Chiware’s woes as there is no one to remind her to take her medications. Due to her age and the fact that she once experienced a stroke back in the day, she now struggles to move from point A to B. She also experiences tremors, sleep disorders, and slurred speech.

Between 2017 and 2018, she defaulted treatment and this led to a spike in her viral load count. This pushed her into depression and other mental health conditions. This is notwithstanding that she takes over eight medications to deal with the numerous health conditions she is now battling. These include Levodopa, Fluoxetine, Atenolol, Hydrochlorothiazide (HCT), Aspirin, Atorvastatin, and TAF/FTC/DTG.

Gogo Chiware is just but a drop in the ocean of millions of other elderly people currently living with HIV and experiencing a myriad of health conditions mainly associated with aging and HIV.

According to UNAIDS data, in 2022, an estimated 24 percent, or 4.2 million of people living with HIV globally were aged 50 years and older, in the East and Southern Africa (ESA) region, 2 million out of 20.8 million, and In Zimbabwe, 22 percent of PLHIV are 50+ (28407).

The UNAIDS however noted that as people with HIV grow older, new challenges are emerging, and concerns affecting people ageing with HIV have both medical and social impacts.

                                                                                 Angeline Chiwentani

Angeline Chiwentani (51), a Zimbabwe woman who has been living with HIV for the past 28 years says she now that she has reached the menopause stage, she is beginning to experience unusual health related conditions.

I just turned 51,” she says. “I have been living with HIV for the past 28 years now and I have been on treatment since 2008. I still take my ARVs religiously.

“However, other things are coming up. Now that I have entered the menopause phase, I am experiencing things I never experienced before. At times I experience hot flashes, and all sorts of things, and I am tempted to think it’s the ARVs at times. I also feel heart palpitations, they come and go and this gets me worried.”

Women like Angeline who have reached menopause and living with HIV experience a myriad of other conditions that come with the condition.

For the first time since the start of the HIV epidemic, 10 percent of the adult population living with HIV in low- and middle-income countries is aged 50 or older. The increased availability of antiretroviral treatments has seen people living with HIV living longer healthier lives. ART effectiveness has led to reduced mortality. Worldwide, an estimated 3.6 [3.2–3.9] million people aged 50 years and older are living with HIV. (UNAIDS).

However, aging with HIV comes with numerous comorbidities. While aging is linked to risks of the development of dementia and other NCDs, PLWHIV has an increased risk of cardiovascular disease and dementia.

The aging process itself can lower energy levels, restrict social encounters, and cause decreased physical and mental abilities. This means that older people living with HIV may suffer more emotional problems and physical stresses than others do. The stigma of living with HIV and the stigma of being older can make more difficult they may be ashamed and hesitate to tell anyone that they live with HIV. They may not be comfortable in support groups that include younger people

However, apart from those already living with HIV, there seems to be an emerging phenomenon where new HIV infections are being acquired among the aged.

Dr Trevor Kanyowa, the World Health Organization (WHO) Zimbabwe National Programs Officer 
for Family and Reproductive Health said HIV prevalence among men aged 50 – 54 years 
increased from 19.5 percent in 2010 to 28.9 percent in 2015 (ZDHS 2015).

“HIV prevalence among people aged 45 and older is increasing while prevalence among younger age groups is decreasing. Older adults comprise an increasingly large proportion of those living with HIV. At the same time, these older adults exhibit a range of behaviors that place them at risk for HIV infection including low levels of condom use and relatively higher rates of multiple partnerships,” said Dr. Kanyowa.

  Dr Trevor Kanyowa

He added that prevalence among older adults cannot be fully attributed to longer survival only aw Sero-conversion is also occurring and the data suggests that several older adults are undertaking behaviors that put them at risk of HIV transmission. He said Sero-conversion may also be occurring because an older person may lose their partners and enter into new relationships.

“Sexually active widowed, married and divorced older people may be less aware of the risks of HIV than younger age groups, believing that HIV is not an issue for older people less likely to use HIV prevention methods to protect themselves from infection.

“Postmenopausal women are less worried about becoming pregnant and may thus be less likely to practice safer sex. Older men and women are more likely than younger people to avoid discussion of their sexual behaviors and healthcare workers are less likely to ask their older patients about these issues.”

He also said older people are more likely than younger age groups to face isolation due to illness or the loss of family and friends, and HIV stigma may prevent them from seeking HIV care and disclosing their HIV status for fear of abandonment and isolation. Ageing with HIV infection according to Dr Kanyowa also presents unique challenges for preventing other diseases because both age and HIV heighten the risk of cancers, bone loss, and cardiovascular disease.

                                                                                         Dr Cleophas Chimbetete

Meanwhile, speaking on why older people are getting new HIV infections, Dr Cleophas Chimbetete, a Clinician and HIV Researcher said the HIV risk perception amongst the elderly is very low.

“These days there is effective treatment for erectile dysfunction so older males are sexually active. One can now just access the blue pill by the street corners. There is no concern for pregnancy so more condomless sex is likely to occur. In women, changes in the vagina such as vaginal wall dryness and thinning increase a woman’s risk of acquiring HIV. Unfortunately, there are currently no campaigns targeting older adults so many perceive themselves to not be at risk of contracting HIV,” said Dr Chimbetete.

He however said PLWH have higher rates of multimorbidity and polypharmacy. Geriatric syndromes such as frailty and falls occur at an earlier age. There is also accelerated aging that occurs due to chronic inflammation and toxicity from ART. Mental health issues are also prevalent in older people living with HIV.

The Veteran’s Aging Cohort Study (VACS) found that PLWH are 1.5 times more likely to have an acute myocardial infarction than the general population. Unfortunately, HIV is not included in the current CVD risk stratification tools. The REPRIEVE study showed that a daily statin dose reduces the risk of cardiovascular disease in PLWH with low to medium risk of CVD Statins and ART interaction.

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