Abstract
Epidemiological data of HIV affected individuals of aged 50 years and above in India are lacking for various reasons. Diagnosing HIV infection among the elderly is challenging as chronic HIV/AIDS can mimic those typically associated with aging in parallel to the myth that elderly individuals lead asexual lives. In this study, low-literate, poor, urban men were the major group. The most common presentation at diagnosis was frailty or unexpected weight loss and neurocognitive impairment, whereas the incidence of TB was much less. Policy makers and social workers should be aware of this descriptive analysis in order to address the emerging issue of HIV among geriatrics and to create a broader awareness programme and more liberal HIV testing among this group. This study also highlights the need for a larger population based study involving elderly HIV infected persons in India.
Introduction
Recent data from the US suggest that both the incidence and prevalence of HIV infection are increasing among people aged 50 years and over. 1 Research in sub-Saharan Africa suggests that these trends are also taking place in more resource-limited settings.2,3 However, very little is known in India about the epidemiology of HIV/AIDS among older people. We do not have exact figures for elderly HIV affected people due to: under reporting; weaknesses in the surveillance system; bias in targeting groups for testing; and other reasons. 4 In the National Health Interview Survey 2006, adults aged 65 years and above had the lowest rates of HIV testing of any age group (11.4%). 5 The elderly know less about HIV/AIDS and may not have any knowledge regarding its spread. Healthcare providers usually do not ask older individuals about their sexual lives, drug use or risky behaviours. 6 Special attention in treating the elderly with highly active antiretroviral therapy (HAART) is needed as many elderly patients have other chronic diseases which may be aggravated with the use of HAART. 7
Methods
This was a retrospective cross-sectional study done among 567 newly detected HIV infected individuals aged 50 years or more at a tertiary care hospital in Kolkata from 2008 to 2012. After obtaining the institutional ethics committee approval, record sheets of the patients were analysed. Epi Info software (2008) was used to manage and analyse the data.
Results
Demographical status of elderly HIV infected patients (n = 110).
Mode of clinical presentations, World Health Organization (WHO) clinical staging, functional status and mean CD4 count.
Discussion
Centers for Disease Control (CDC) reported that those aged 50 and older accounted for approximately 17% of new HIV/AIDS diagnoses and 36% of people living with HIV/AIDS (PLHA). 8 In a prospective cross-sectional study conducted among elderly HIV patients in Tanzania seropositivity was found to be 15% (38/253); by sex the prevalence was 18.5% (28/151) in men compared to 9.8% (10/102) in women. 9 A similar study conducted in Jodhpur, India, reported that of 773 patients tested for HIV over the age of 50 years, 46 (5.95%) were positive for HIV-1 antibodies. 10
Elderly HIV infected patients from rural areas (men = 43%, women = 44%) represent a lower portion than their counterparts urban (men = 57%, women = 56%) which is also reflected in other studies. Most were either illiterate or insufficiently literate to be aware of the importance of HIV testing. Although most (81%) of the men were employed at the time of the serodiagnosis the majority (79%) earned less than 5000 Indian Rupees (INR) per month (less than US$100). In a study from Brazil, the majority of the participants reported less than 7 years of formal education and had a per capita household income of less than US$600. 6
From the serostatus of spouse, most of the wives of elderly male HIV patients are discordant (32%), whereas most of the husbands of elderly female seropositive HIV patients are concordant (33%). This reflects the fact that men are more likely to engage in heterosexual promiscuity whereas the women are more likely to be infected via their husbands. In 12% (n = 70) of study populations the serostatus of the spouse was unknown. This suggests that the magnitude of elderly HIV patients and burden of HIV infected elderly patients is underrepresented and can be expected to increase in the near future as shown over last 5 years in our study. Heterosexual contacts were the main cause of HIV infection among the elderly in our study. In a study from Jaipur, India, the mode of transmission was heterosexual in all the seropositives. 10
Those who are found to be asymptomatic at the time of diagnosis constitute a larger portion among women (27%) than men (6%). Surprisingly, the WHO functional classification does not reflect the suffering of the elderly HIV/AIDS patients. In our study, the majority (men = 42%, women = 45%) were functionally ‘working’ at the time of diagnosis. The most common clinical presentations of HIV/AIDS among the elderly in our study population were frailty and unexplained weight loss which superseded an incidence of TB. The next common mode of presentation was HAND which is present in more than 40% of PLHA and 10%–20% of HIV/AIDS patients at the time of presentation. In a Tanzania study, the main presenting feature among HIV positive patients were: wasting (44%); fever (39.5%); pallor (34.2%); and weight loss (31.6%). 9
Conclusion
An increasing proportion of HIV infections are occurring in older adults because they are the least likely to practice safe sex, and late-life changes in the reproductive tract and immune system may enhance a susceptibility to HIV acquisition. Policy makers, social workers and researchers should study this descriptive analysis in order to address the emerging issue of HIV among the older age group, to consider how to introduce wider awareness programmes targeted at older people and to conduct larger population based study involving elderly HIV infected people from India.
Footnotes
Declaration of conflicting interests
None declared.
Funding
This research received no specific grant from any funding agency in the public, commercial or not-to-profit sectors.
Author note
The Institutional Ethics Committee of Medical College Kolkata, India has approved the research proposal. AT, BS and PT were the attending physicians; BB did the laboratory work; DK, S Ray and S Rana followed the case records and undertook the literature review; AT, DK and PT prepared the manuscript; PT and S Ray edited the manuscript; and BS and BB provided intellectual support.
