Human immunodeficiency virus (HIV) infection is often overlooked in older individuals. An understanding of the knowledge and beliefs of older individuals to HIV infection is an essential component not only in the planning of care for older individuals but also for younger family members affected or infected with HIV.
AIM: To describe the knowledge and beliefs of individuals older than 50 years to HIV infection in a tertiary medical centre in South Africa
A cross sectional study using convenience sampling was undertaken between August 2006 and January 2008. Fifty-eight individuals older than 50 years were interviewed in the medical in-patient and out-patient wards of a tertiary care hospital. Demographics and knowledge of HIV acquisition, transmission, treatment and prevention was determined.
The mean age was 66.6 11.58 years and 643.93% were female.All of the individuals where aware of HIV infection .Poor assessment of personal risk to HIV acquisition was noted despite adequate knowledge about modes of transmission of HIV infection. Lack of condom use was present in 14.55 % individuals despite 50% reporting current sexual activity. There was a lack of knowledge with respect to the use of antiretroviral drugs in the prevention of mother to child transmission and HIV infection.
Conclusion: Interventions are needed in individuals older than 50 years to increase condom use and access to testing and HIV treatment.
Following the introduction of highly active anti-retroviral therapy (HAART) in South Africa, the number of older adults (age 50 years and older) living with HIV infection is expected to steadily increase. Consequently, the prevalence of HIV infection in individuals greater than 50 years in the population is likely to increase. In the United States there has been an increase(from 20 to 25%) in the proportion of older individuals infected with HIV infection from 2003 to 2006.(CDC 2008)
In South Africa there is a lack of age-specific information on treatment,interventions and prevention in older adults.Perons over 50 years are not routinely tested for HIV infection and often present with HIV-related illnes ses in the advance d stage of HIV infection . The presentations are further complicated by the overlapping presentations of age-re lated co-morbid illnesses such as occult malignancy and Alzheimer's disease . (Lee, Leo et al. 1997)
The ability to provide the required care for these older adults is a crucial health care challenge. This will require optimization of HIV prevention of older individuals through the provision of comprehensive service access for both prevention and treatment of HIV care within the context of care for the elderly.
Older adults are not viewed as 'high risk' for HIV infection(Mack and Ory 2003; Gebo 2009) and are generally excluded from voluntary counseling and testing (VCT) programmes. (Coleman and Ball 2007) Many older adults seek medical care for other medical illnesses and this provides an opportunity to prevent and treat HIV infection. The National 2008 estimate for HIV prevalence amongst South Africans for all age groups is 10.6%.(Shisana O and Mbelle N) HIV prevalence in those older than 50 years ranged from 10.2% in males between 50-54 years to 1.8% in females 60 years and older.(Shisana O and Mbelle N) This study assessed the knowledge, beliefs and attitudes, measured by questionnaire in a cohort of older individuals in a tertiary medical care center in South Africa.
This cross sectional study was conducted between August of 2006 and January 2008. Data was obtained through a structured questionnaire administered in person in either the medical ward or outpatient clinic. The length of the interviews was approximately 45 minutes. Information obtained from participants included demographic characteristics, health status, knowledge about HIV infection, HIV prevention and treatment of HIV infection. The response was either 'yes, no, I do not know'.
Confidentiality and informed consent processes were in compliance with the research protocols of the University of Kwazulu Natal.
Data analysis was conducted with SAS (version 9.2 SAS Institute, Cary, NC, USA). Descriptive analysis of results is expressed as percentages for categorical variables and mean and standard deviation for continuous variables. Chi square tests or Fischer's exact tests were used to assess the association between categorical variables. Means were compared using analysis of variance. Odds ratios and estimates with 95% confidence intervals were calculated using multiple logistic regressions. Two sided p values less than 0.05 were defined as statistically significant.
Demographic factorsfeatures of Individuals
A total of 58 individuals were enrolled. Table I shows the baseline demographic factorsfeatures of interviewees. The mean age was 66.6 11.586 years with a range from 50 to 94 years .There was no significant difference in age between males or females (Table IV) and the majority (643.93%) of subjects were female; living with an average of > 2 persons in the household. (Table I) The predominant race was black (81.9782%).All patients were heterosexual and 45.946% were currently married and 42.643% were widowed. Approximately 18% had no formal education and only 4.95% had a tertiary education. The reported chronic conditions included hypertension (8483.57%), cardiomyopathy (6464.42%%), diabetes (61.962%), renal disease (55%) and valvular heart disease (398.46%). A history of pulmonary tuberculosis was present in 90% of patients. A small proportion (8.47%) were currently providing support to an HIV/AIDS infected person.
Risk factors for HIV infection in those older than 50 years
The number of lifetime partners ranged from 0 - 50 partners and 50% of individuals had a current sexual partner. The number of current sexual partners ranged from 0-4 (mean 0.560.74, range 0-4).Only 14.55% reported the use of male condoms during sexual intercourse.
A history of a sexually transmitted infection was reported in 81.03% of subjects and 5.26% reported a history of rape or sexual assault.Females were more likely to report a history of sexually transmitted disease compared to males(p=0.01) .Thirty one percent of individuals received a blood transfusion of which 24.14% received the transfusion after 1990.
Table IV shows comparisons of males and females in terms of age and risk factors for HIV infection. The results of bivariate analyseis indicated that there were no significant differences in age by gender. Furthermore, bivariate analysies indicate that there was noa significant difference (p=0.03) in the overall mean number of current of partners and the number of lifetime partners reported (p=0.01) between the 2 groups. Females had 3.56(95% CI 0.749-16.873, p=0.11204) times higher odds of partaking in sexual intercourse without male partner use of condoms.This was not statistically significant.
Knowledge of HIV infection transmission, HIV prevention and HIV treatment (Table III)
All subjects had heard of HIV infection and 832.98% correctly identified HIV as a virus. The source of HIV information or education in the majority of subjects was television (865.7%). In 710.9% of individuals a need for more knowledge and information about HIV infection was expressed. Only 532.54% had heard of the voluntary counseling and testing programmes and 53.45% stated that they would consider having an HIV test if this service was offered to them. Individuals were less knowledgeable about prevention of mother to child transmission, only 39.13% were aware of the use of antiretroviral therapy in preventing mother to child transmission of HIV infection.
72.4% of individuals acknowledged that there was no cure for HIV infection and 68.42% were aware of the availability of treatment for HIV infection. Heterosexual contact was identified by 100% subjects as a mode of transmission for HIV infection. However, 81.03% of individuals identified mother to child transmission as a mode of HIV transmission (Table III)
There is a lack of age-specific data on treatment, interventions and prevention programmes in older individuals with respect to HIV infection amongst individuals greater than 50 years.(Mack and Ory 2003; Kyobutungi, Ezeh et al. 2009)Many health practitioners underestimate the risk of HIV acquisition and may fail to consider HIV infection in older adults.(Manfredi, Calza et al. 2003; Orchi, Balzano et al. 2008; Gebo 2009)This is a missed opportunity for HIV prevention, education and treatment. This cross sectional study assessed the knowledge, beliefs and attitudes towards HIV infection in older adults accessing a tertiary care service in South Africa.
Older adults sought care for a variety of medical conditions that includincluded hypertension. cardiomyopathy, diabetes and renal disease. About 90% of individuals had a history of pulmonary tuberculosis.This highlights the multiple co-morbidities present in adults older than 50 years.(Gebo 2009)Furthermore, there is insufficient information as to whether these co-morbidities are present to the same or greater extent in HIV infected individuals of the same age.(Gebo 2009) Managing individuals older than fifty years and HIV infected with HAART will further complicate HIV care.(Funnye, Akhtar et al. 2002; Manfredi, Calza et al. 2003)
Risk of HIV infection in older adults
In South Africa there is a lack of studies describing the perceptions of older persons with respect to HIV infection. Older American adults, especially older heterosexuals did not perceive themselves to be at risk for HIV infection and as a consequence were less likely to partake in prevention measures. (Orchi, Balzano et al. 2008) In this survey, the majority (87.04%) of adults older than 50 years thought that persons older than 50 years were at risk of HIV infection.
Previous studies have indicated a low frequency of condom use by the elderly.(Shisana O and Mbelle N ; Lee, Leo et al. 1997; Orchi, Balzano et al. 2008) In this study, about 50% of subjects were currently sexually active and only 14.55 % utilized male condoms. This was in contrast to the belief that 84.21% identified lack of condom use as a risk factor of acquiring HIV infection. The use of condoms in this study is lower than that reported in the HIV household population based study that found the lowest level of condom use in males(4039.9%) older than 50 years.(Shisana O and Mbelle N) However, the rates of condom use at last sex reported by men older than 50 years had increased 5 fold in 2008 when compared to the 2002 and 2006 national surveys.(Shisana O and Mbelle N)
Multiple current sexual partnerships were more common in males (3.34%) compared to females in this study. In the national population based study, a similar finding was observed, however males older than 50 years reported a significant decrease of having more than one sexual partner in the last year (7.5% in 2002 to 3.7% in 2008). (Shisana O and Mbelle N)Both in this study and the population based study(Shisana O and Mbelle N), females older than 50 years did not commonly engage in multiple sexual partnerships.
The failure of access and awareness of voluntary teaching programmes to reach individuals in this age group is similar to that observed in the national population based study. (Shisana O and Mbelle N)This is an important concern and needs to be considered in future planning of both HIV services and services for older individuals. Testing for HIV infection is an important entry point into HIV treatment, prevention and social support services. Knowledge of HIV status is an important initiator of behaviour modification and knowledge of services may result in an increase use of services.
Knowledge of HIV infection
Awareness of HIV infection and modes of HIV transmission was sufficient in those interviewed; however, knowledge of HIV prevention strategies was not optimumal in interviewees. The willingness of more than half of individuals older than 50 years to agree to have an HIV test indicates that this age group recognizes the importance of HIV testing despite not having easy access to VCT programmes. All individuals were aware of HIV infection and a satisfactory knowledge of mode of transmission was noted.
However, t There was a lack of knowledge with respect to available interventions for the prevention of mother to child transmission of HIV infection amongst the interviwees. Prevention of mother to child transmission of HIV infection is an important HIV prevention intervention and older individuals may play an important role in encouraging and enabling access to this intervention for younger individuals.(Williams, Knodel et al. 2008) Intergenerational support exchanges are common in South Africa. Given the disasterous impact of the South African HIV epidemic on adults of reproductive age, older adults are often the caregivers of AIDS patients (children, grandchildren). This care extends to physical, financial and emotional support. A recent survey of households in South Africa revealed that two-thirds of caregivers were female, with almost a quarter of them over 60 years.(UNAIDS 2004)Therefore empowering this age-group with HIV prevention knowledge may be an important prevention intervention in the fight against HIV infection.
Limitations of study
The sample size is too small to allow meaningful analyses of data and generalization to all older individuals. This is a convenience sample with cross sectional study design and hence exposure and outcomes were measured at the same time. The study's results may be affected by recall bias and changing behaviors. This interview is based on self report and the nature of the questions with respect to sexual behavior may have been influenced by social desirability bias.
Older individuals are at risk of HIV infection and there is an urgent need to ensure access to HIV counseling in health care settings that service older individuals. Knowledge about HIV status in the elderly has been neglected and may be an important entry point for HIV care. Lack of awareness of VCT programmes and poor self perception of HIV infection risk is of concern. Future intervention programmes need to consider targeting older individuals for HIV infection testing.
The willingness and enthusiasm of the participants is hereby acknowledged and appreciated. Halima Dawood was supported by the Columbia University-Southern African Fogarty AIDS International Training and Research Program (AITRP) funded by the Fogarty International Center, National Institutes of Health (grant # D43TW000231).
Conflict of interest: none
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