HIV-AIDS in the elderly: the invisible vulnerable28/05/2019
Since its emergence more than three decades ago, the Acquired Immune Deficiency Syndrome (AIDS) appeared loaded with stigmas in relation to people living with the Human Immunodeficiency Virus (HIV). Initially, it was associated with certain social groups such as homosexual men, users of injectable drugs and sex workers. Over time it has spread globally, reaching individuals without distinction of age or sex.
Although the profile of carriers of this disease has been expanding, making it increasingly younger and older at the same time, data from the Pan American Health Organization indicate that “the HIV epidemic in the Latin American region disproportionately affects certain subpopulations, including gay men and men who have sex with other men (MSM), transgender women and sex workers. In Latin America, these three groups of key populations represent approximately half of new infections in 2017. ”
According to UNAIDS, globally, new HIV infections in adults and children have been reduced by 40% from the 1997 peak. While new HIV infections in adults have stagnated, UNAIDS shows also that there are no significant reductions. In Latin America, the annual number of new HIV infections in adults has increased by 2% since 2010.
South America, like most of the world, experiences an accelerated increase in life expectancy and the median age of its population. Older adults carry out activities that perhaps previous generations did not perform due to health limitations, access to medication, social and economic mobility and even taboos and prejudices.
The prolongation of life expectancy allows, among other things, to prolong the sexual life of this segment of the population and with it an increase in exposure to HIV and other sexually transmitted diseases (STDs).
Rags are “oldies” and “grandparents” were the ones from before
Language and words change along with social subjectivities. Certain words are questioned and/or changed in their use, for example, because of gender and inclusive language matters. Not so long ago, it was quite common to hear or read about “oldie” and “grandparents”. It still happens today but there is always a call for attention from those mentioned.
“Rags are oldies, I am not an oldie” says a 72-year-old university professor in front of a classroom full of students. “Whose grandfather? If I do not have children, I am not a grandparent” says a man who is around 68 and plays beach soccer with several colleagues from younger generations.
Things by their name, let’s talk about older adults. But who do we call seniors? How old must a person be to be elderly? According to the World Health Organization (WHO), a person older than or equal to 60 years old is considered to be elderly for developing countries and 65 years old for developed countries.
“These considerable increases in population with more years of life, which can sometimes be considered a burden on health systems, are also and mainly a measure of social success in maintaining populations with increased life expectancies once they reach 60 years”, highlights a study by the South American Institute of Government in Health (ISAGS) that addresses the challenges of population aging for health systems in the region.
Susana Cabrera, director of Sexually Transmitted Infections and HIV of the Ministry of Public Health of Uruguay, told Salud al Sur that “prevention policies and sex education campaigns are generally aimed at young people. This is associated with a concern about what is supposed to be the age in which there is greater sexual activity, as well as a higher probability of having multiple partners and less stability in personal relationships. In this way, it becomes necessary to make visible the situation of the elderly”.
For Cabrera, “it is important to note that there are more and more people with HIV over age 50, not only because people can acquire the infection at any age, or because the diagnoses may be late, but because people with HIV can live for many years with a life expectancy similar to people without HIV, thanks to advances in antiretroviral treatment”.
In relation to the late diagnosis, the Uruguayan Health Ministry official points out that in that country there is a higher HIV proportion in men. “While women have more opportunities to receive an HIV test because of their greater approach to the health system (e.g. gynecological consultation, PAP, pregnancy), men usually have little contact with the health system until old age. This is reflected in that the average age of diagnosis in men is 40 years old while in women is 37”, says Cabrera.
Alessandra de Matos Santos, researcher at the Open University of the Third Age of the State University of Rio de Janeiro (UERJ) and author of a study on the “Vulnerability of older women to HIV” notes that in Brazil “the increase in Number of HIV cases in the elderly population is associated with:  aging of the population;  increase of the survival rate of people living with HIV/AIDS; and  access to medicines for erectile problems. These factors that have allowed a prolongation of sexual activity of people over 50 years.
Although Alessandra’s study is from 2011, data from the 2018 HIV/AIDS Epidemiological Bulletin of the Ministry of Health of Brazil confirm an upward trend for this age group in that country. Among women, the rate of detection of the virus showed a drop in almost all age groups, except in the age of 60 and over. In this social group, there was observed an increase of around 20% when the years 2007 and 2017 were compared. When analyzed by gender, the detection rate practically doubled in men.
Jackie, the 49 year old “old lady”
Jackeline Romero, La Jackie, as everyone knows her in the Argentine city of Rosario, survived her 35th birthday and is now older than most trans people she knows. In Argentina, the life expectancy of a trans person is 35 years old. In Brazil, it is 32. For that reason, she calls herself an “old woman”, a survivor. She survived the harshness of being a sex worker, prostitution on the street, police abuse and HIV diagnosis at a time when life expectancy was uncertain for the carriers of this disease, by then virtually unknown. It was 1984 and Jackie was 14 years old. She became the first trans diagnosed with HIV in Rosario, the third largest city in Argentina. At that moment, the LGBTI activist that she is today was born.
“When I say that I feel old, I mean that I lived more than the average trans people and transvestites, since, unfortunately, it is not usual that we overcome the age of 35,” says Jackie to Salud al Sur through WhatsApp. And she continues: “the transmission of HIV in older adults is due to the fact that this social group does not have information in relation to the subject”. “it also influences the lack of awareness when it comes to having relationships, since many people find it difficult to use condoms”, she adds.
For her particular life story, “the old woman” Jackie created the Diversa Positiva network, a non-governmental organization for inclusion. Not only people within LGBTI community, but also all those who feel identified in the struggle for the human rights of the people with the greatest vulnerability, participate in it.
Elderly population and government policies
The characteristics of existing public policies focused on the elderly population with an emphasis on health were reviewed by ISAGS in a specialized study. In relation to specific policies on HIV, two countries were highlighted: Bolivia and Guyana.
In Bolivia, the National HIV/AIDS Program has a universal nature and includes older adults in all its activities and benefits, which include diagnosis, monitoring and treatment with antiretroviral drugs and nutritional support. In 2016, it was reported that 54% of those served by the program were over 50 years old.
In Guyana, the main strategic guidelines for health policies during the period between 2013 and 2020 were established in the “Health Vision 2020” document of the Ministry of Health. Recognizing the importance of the HIV/AIDS matter in Guyana, it includes a national strategic plan that aims at the elimination of HIV in that country by the year 2020. It identifies the elderly among the groups with HIV to be attended by the policy.
On the other hand, in Brazil, the National Program on Sexually Transmissible Diseases and AIDS of the Ministry of Health conducted a study in 2003 on the sexual behavior of the population of 60 years of age and older. The data showed that 39% of this group had an active sexual life and that heterosexual relationships with risky behaviors predominated. Unprotected sex, multiple partners and problematic use of drugs and medications were risk factors identified.
Stigmatization and prejudices
Stigmatization and prejudice in relation to HIV are as old as the disease. The ISAGS study concludes that, despite the wide variations both in the characteristics of population aging and in the approach of policies aimed at older adults among the South American countries, there are well-known common aspects in terms of principles, strategies and even in the institutionalization of interventions.
For these reasons, the survey suggests adapting health systems to elderly populations, creating services that provide comprehensive care focused on the elderly person and ensure access. It is fundamental that the right to sexual health be contemplated within those systems since having a prolonged sexual life is a synonym of health for all.