This document summarizes a presentation given by Professor Niyi Awofeso on addressing HIV infection risks and consequences among elderly (>50 years) sub-Saharan Africans. It provides statistics on HIV prevalence and the physical, mental, and socioeconomic burdens of HIV/AIDS in this population. It also discusses policies and programs that could help reduce infection risks, such as expanding HIV testing and treatment, promoting circumcision, implementing social pensions and healthy aging programs, and reducing stigma through education. Successful models from Botswana and South Africa are presented.

1. Addressing HIV Infection Risks
and 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.

3. Presentation Outline
Basic health statistics about Africa
HIV/AIDS epidemiology among the elderly
(> 50 years) in Sub-Saharan Africa (SSA).
Physical, mental health and socio-economic
burdens of HIV/AIDS among SSA’s elderly.
Evidence-based policies and programs to
address socio-economic burdens and
HIV/AIDS infection risks among SSA’s
elderly, including lessons from Asia-Pacific
experience

4. Sub-Saharan Africa – Basic Statistics
(WHO-AFRO, 2011)

5. Basic Statistics – African Region
(WHO-AFRO, 2011)

6. Basic Statistics – African Region
(WHO-AFRO, 2011)

7. Basic Statistics – African Region
(WHO-AFRO, 2011)
Life expectancy at birth, by region & by gender.

8. Basic Statistics – African Region
(WHO-AFRO, 2011)
Per capita total expenditure Total health expenditure
on health (PPP). as % of GDP.

9. Basic Statistics – African Region
(WHO-AFRO, 2011)
Physician-to-population Nursing and midwifery
ratio (per 10,000 personnel-to-population
population) in WHO ratio (per 10000
Regions, 2000–2009 population) in WHO
Regions, 2000–2009

10. 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

11. HIV/AIDS and SSA’s elderly

12. Global HIV/AIDS Epidemiology

13. Africa’s HIV/AIDS Epidemiology:
http://www.youtube.com/watch?v=hzQQiCPWSYA

14. Extent of HIV/AIDS among SSA’s elderly
About 3 million elderly individuals in Africa are living
with HIV infection, approximately 10% of all HIV
infections (Negin & Cumming, 2009).
The estimated prevalence of HIV infection among SSA’s
elderly and those aged 15-49 are similar at about 5%.
The proportion of elderly people in Africa infected with
HIV/AIDS is increasing: good news because increased
access to treatments means that patients are living with
longer life expectancy; bad news because meeting the
complexities of geriatric care for HIV-infected adults
will further challenge overwhelmed health systems.

15. HIV/AIDS Among SSA’s elderly (> 50 years)
Source: Demographic Health Surveys, 2003-7
(Rammohan % Awofeso, 2010).

16. HIV Prevalence Among SSAs over 50 years old
(Negin & Cumming, 2010).

17. SSA’s Demographic Transition – over 60yo
Source: UN WPT, 2004,
and NAS, 2007.

18. HIV/AIDS and Africa’s Demographic Transition
(erroneous) Modelled Life expectancy trends in
selected African nations & WB 2009 estimate for
South Africa:

19. HIV/AIDS Among Elderly SSAs
Elderly SSAs constitute ~ 4.7% of the general
population & 5% of the total adult population infected
with HIV.
Based on limited data on elderly SSA males obtained
from DHS 2003 – 2007 surveys, HIV prevalence
among SSA’s elderly ranged from 1% in Ethiopia to 19%
in Zimbabwe.
A 2001-2 sero-survey of 133 male Ethiopian cataract
patients aged 50-59 found HIV prevalence of 9.1%,
higher than the 1% prevalence reported in the DHS, as
well as a 6.3% HIV prevalence in Ethiopians aged 15-49
years (?? HIV associated cataract. Rasmussen et al, 2011)

20. HIV/AIDS Among Elderly SSAs
Kenya’s DHS 2003 data documented male HIV
prevalence as 4·6% for the 15—49 year age-group, and
5·7% for the 50—54 year age-group.
The prevalence of HIV notification in men aged 50—54
years rose sharply between 2003 and 2008 (from 5·7%
to 9·1%), while younger cohorts were generally static or
declining in prevalence.
HIV prevalence was highest in the wealthiest quintile
and increased in both cohorts for the two survey periods.
Further, over 60% of men aged 50—54 years who tested
positive lived in rural areas. – Mills, Rammohan,
Awofeso, Lancet, 2010.

21. “Risk factors” for HIV infection among SSA’s
elderly
Source: 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

22. Physical burden of HIV among SSA’s elderly
Wasting syndrome
Increased vulnerability to infections:
Tuberculosis, Malaria, Giardia, Salmonella,
Cytomegalovirus, Candida, Cryptococcal meningitis,
Toxoplasmosis, Cryptosporidiosis.
Increased vulnerability to cancers: Kaposis
sarcoma, Lymphomas.
Neurological complications: AIDS dementia
complex, Vascular myelopathy, Peripheral
neuropathies.

23. Physical burden of HIV among SSA’s elderly –
Wasting Syndrome
Wasting syndrome is
defined as weight loss
in excess of 10% from
baseline that is
associated with
chronic diarrhoea,
fever, or weakness.
Second most common
AIDS-associated
condition in SSA.

24. Mental Health Burden of HIV/AIDS
(WHO, 2008)
In United States, prevalence of mental illness
among HIV+ve patients range from 5% and
23%, compared with 0.3% to 0.4% in the
general population.
Mental health problems & substance abuse
double behavioural risk factors for HIV spread.
Studies in both low- and high-income countries
have reported higher rates of depression &
psychological distress in HIV-positive people
compared with HIV-negative control groups.

25. Mental Health Burden of HIV/AIDS
(WHO, 2008)
Mental health problems impair care seeking &
treatment adherence among those diagnosed with
HIV/AIDS.
Direct effects of HIV on the brain include: HIV
encephalopathy, depression, mania, cognitive
disorder, and frank dementia, often in
combination.
Mental illnesses like depression and drug addiction
can themselves be risk factors for HIV. Conversely,
people with HIV are more likely to develop mental
illness than the general population.

26. Mental Health Burden of HIV/AIDS
There are no specific mental health services
for people living with HIV in SSA
Training of African healthcare workers on
mental health problems associated with HIV is
inadequate.
A 2008 study by South Africa's Human
Sciences Research Council found that 44% of a
sample of 900 HIV-positive individuals were
suffering from a mental disorder (Freeman,
2008).

27. 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

28. Economic Burden of HIV/AIDS Among SSA’s
Elderly
Among SSA’s elderly, economic status has a bimodal
influence on HIV transmission. Thus, burden varies
widely. Nevertheless, HIV infection is associated with
socio-economic disadvantage in all wealth quintiles

29. Economic Burden of HIV/AIDS Among SSA’s
Elderly Caregivers
In a recent study in Kenya, About 11% of older people
reported to have provided care to someone with a chronic
illness, out of whom 41% were classified as having cared for
someone with a HIV/AIDS. Health care costs were
significantly higher among HIV/AIDS caregivers
(Chepngeno-Langat et al, 2010).
Caregiving is associated with depressed economic status
among SSA’s elderly, except in societies with strong extended
family ties, free HIV treatment or wealthy patients.

30. 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.

31. Social Burden of HIV infection – Stigma &
Discrimination

32. HIV Status and Discrimination
http://www.youtube.com/
watch?v=buQm23Nw49s

33. Social Burden of HIV/AIDS Among the Elderly
Average decline in GDP in Africa due to HIV/AIDS has
so far oscillated around 1% per annum, due, in part, to
low labour costs and inadequate consideration of the
non-informal sector, and unpaid carers work by the
elderly in such modelling.
The presence of HIV/AIDS in a household may result in
a depletion of household income earning capacity and
of household savings and assets.
The economic costs of HIV/AIDS, the stigma
surrounding the disease that leads to discrimination
and social exclusion widen socio-economic inequalities.

34. 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.

35. Policies to address HIV/AIDS Among Africa’s
Elderly – Research on the extent f the problem
A 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 among
individuals aged 50 years or over (Negin et al. 2010). In
Botswana, one of the countries most affected by the HIV
epidemic, the 2030 projected population pyramid with and
without HIV/AIDS is shown below:

36. Policies to Address HIV/AIDS Among Africa’s
Elderly – Improve HIV/AIDS Care
HIV policies in the elderly need to address
encumbrances to early diagnosis via voluntary
testing in culturally appropriate contexts
(ABC-D).
More clinical trials among elderly patients, to
determine optimal dosage and response
profile for anti-retroviral drugs with minimal
side effects.
Address multiple chronic health needs of
elderly SSAs living with HIV.

37. Policies to address HIV/AIDS among Africa’s
elderly – reduce HIV infection risk
Absolute Poverty (lower Reduce poverty,
figure) and gross enrolment Improve educational
ratio 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.

38. Policies to Address HIV/AIDS Among Africa’s
Elderly – Social Pension
Only 6 of 47 SSA nations currently operate state
provided non-contributory regular cash transfer to
older citizens.
Such support is needed in SSA because older people
are often disproportionately affected by poverty and
the majority of older people have no regular income.
In addition to alleviating poverty for older people,
social pensions have intergenerational effects as they
stimulate school enrolment and continuation and
improve nutrition for the younger generation being
cared for by Africa’s elderly (Kakawani and Abbarao 2005).

39. Policies to Address HIV/AIDS Among Africa’s
Elderly – Healthy Ageing Programs
Healthy ageing is the process of optimising
opportunities for health, participation, and security
in order to enhance quality of life as people age.
Currently, very few healthy aging initiatives exist in
Africa.
Healthy ageing by itself may increase risky sexual
activity if it is not complemented by tailored health
education programs. Mass health education
messages targeted at elderly cohorts discouraging
concurrent sexual partners - “zero grazing” - and
advocating for protected casual sex are important
behavioural change strategies to complement healthy
ageing initiatives.

40. Policies to Address HIV/AIDS Among SSA’s
elderly – Stigma Reduction Surveys and Policies
Perceived Stigma Internalised shame
1.I am accused by others for being the 1. I am punished by evil
spreader of AIDS in the community 2. My life is tainted
2. People gossip about my HIV status 3. I am angry with myself for
3. People look down on me getting HIV
4. The society isolates me 4. I am a disgrace to society
5. I feel discriminated by health 5. My life is filled with shame
workers
6. I feel guilty for being the source
6. I feel my life in this society is lonely of disruption in the family
7. I worry about how other kids treat 7. I feel my life is worthless
my children in school as a result of
my HIV 8. I feel my reputation is lost
8. I worry about how others will treat 9. If possible I want to conceal my
my family members as a result of my HIV status for life
HIV

41. Policies to Address HIV/AIDS Among Africa’s
Elderly – End-of-Life Care
Depending on the prevalence of HIV infection, the
number of people who require end-of-life care every
year in SSA varies from 0.3% – 1%.
Over a third of all HIV+ve patients studied in five
SSA nations were dissatisfied with the quality of
palliative care provided. Most elderly people studied
and experienced stigma and severe financial stress in
relation to payment for palliative treatments
(Sepulveda et al. 2003).
Policies for improved provision of pain management
services are urgently required.

42. Successful Program for Addressing
Early 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.

43. HIV Prevention Programmes
Soul City: Commenced in 1992, Soul City is a television
documentary and mass media intervention which aims to
prevent HIV by increasing knowledge, improving risk
perception, changing sexual behaviours, and questioning
potentially harmful social norms. Some of the episodes
are focussed on elderly HIV risk prevention.
The overall goal of the campaign is to reduce new HIV
infections in South Africa by 10% by 2011. By mid-2011,
there were 5.38 million infections among the population
of 50 million, down from a UN-estimated figure of 5.6
million in 2009.
In 2009, the Soul City One Love campaign reached 25% of
population aged 50 and over. Evaluation of the One Love
in terms of safer sex practices was positive, although
concurrent partnerships actually increased among
viewers.

44. Should Circumcision be Promoted as HIV
Prevention Strategy Among Elderly SSA Males?
Recent studies have shown that circumcision reduces
infection rates by 50 to 60% among heterosexual
African men aged 18-35 years. Mathematical models
have predicted that one new HIV infection could be
averted for every 5 to 15 men who are newly
circumcised.
“Countries with high prevalence, generalized
heterosexual HIV epidemics that currently have low
rates of male circumcision consider urgently scaling up
access to male circumcision services.”- WHO, 2007.
About 60% of African men are already circumcised,
but in Southern Africa (the region worst affected by
HIV) the circumcision rate is less than 20%.

45. Should circumcision be promoted as HIV
prevention strategy among elderly SSA males?

46. 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.

47. Lessons from Asia-Pacific region - Leadership
Australia provides funding for “Without leadership, the
the Asia Pacific Leadership fight against AIDS becomes
sporadic, reactive, without
Forum provides funding for focus, lacking resources,
the design & implementation and will eventually lose
of HIV strategies. steam. In most countries,
national leadership spells
Since 2006, Australia has had
the difference between the
an Ambassador for HIV. This slowing down and the
role encourages political, acceleration of the spread
business and community of AIDS.”
leadership on global and - H E Dr Susilo Bambang
regional HIV issues, and Yudhoyono,
drives debate and advocacy President of the Republic of
Indonesia, Bali HIV
on key policy or programming
Conference, 2009.
areas.

48. Lessons from Asia-Pacific Region – Civil Society
In the Asia Pacific, Australia supports and helps
strengthen regional civil society organisations such
as the Asia-Pacific Network of People Living with
HIV/AIDS (APN+) and the Coalition of Asia Pacific
Regional Networks on HIV/AIDS (7 Sisters).
Australia also supports the Asia regional hub of the
International HIV/AIDS Alliance in Phnom Penh.
The Alliance helps develop civil society
organisations’ skills in advocacy, leadership and
financial management. With more knowledge and
confidence, these organisations can be a real voice
for civil society at the regional level.

49. Lessons from Asia-Pacific Region – Improving
Care and Treatment
Since 2006, Australia has “… Prevention,
funded Clinton Health treatment, care and
Access Initiative projects support for those
in China, Vietnam, infected and affected by
HIV/AIDS are mutually
Indonesia and Papua New reinforcing elements of
Guinea. The aim is to an effective response
remove obstacles to people and must be integrated
receiving antiretroviral in a comprehensive
therapy by improving the approach to combat the
distribution and access to pandemic.”
anti-retroviral drugs. -UNGASS Political Declaration on
HIV/AIDS, 2006

50. -
Lessons from Asia-Pacific Region - Advocating
for Human Rights
AusAID has provided “By repealing these
punitive HIV laws and
funding for the making what is “hidden”
Global Commission no longer “hidden” and
on HIV and the Law. by attacking
discrimination,
The Commission is harassment, black mail
investigating how and sexual abuse,
vulnerable groups will be
punitive laws and able to access services far
human rights more effectively than at
violations can block present”.
- Dame Carol Kidu, Minister for
effective HIV Community Development, Papua New
Guinea
responses.

51. Lessons from Asia-Pacific Region – Alleviating
Socio-Economic Impact
“HIV deepens poverty, exacerbates hunger and
contributes to higher rates of TB and other
infectious diseases.” Ban Kim Moon, UN SG,
2011.
The World Food Program was one of the first
agencies to provide nutritional support to people
on antiretroviral therapy. Since 2001, AusAID
has been funding the World Food Program in
Zimbabwe – a major component of this
operation is support and food assistance to
people living with HIV and their carers.

52. Lessons from Asia-Pacific Region – Developing
Capacity for Research and Sustainability
Australia has built improved monitoring and
surveillance into many of its HIV programs, including
in Papua New Guinea. Since 2008, Australian funding
has helped establish over 100 HIV testing sites in Papua
New Guinea—half of the country’s total public testing
sites.
In Bangladesh, Bhutan, India, Nepal and Sri Lanka,
AusAID has conducted rapid assessments of risk
behaviour and HIV knowledge among people who inject
drugs and their sexual partners.

53. 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