Older adults living with the human immunodeficiency virus (HIV) are set to multiply worldwide [1–3]. HIV/AIDS is a major public health problem among older adults, appeoximately 6 million people over the age of 50 years are living with HIV worldwide. In sub-Saharan Africa, approximately 3 million people older than 50 years of age, are HIV-infected, which represents an average of 14% of affected adults and 11% of adults on antiretroviral therapy (ART) [5,6]. In Nigeria, a cross-sectional study at one of the largest treatment centres, reported that 10% of the studied population were aged, 51 to 60 years, while 0.6% were >60 years . At the national level, 54% of the 3.4 million people that were living with HIV in 2012 were between 15 to 64 years. The recently concluded 2018 Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS), a household-based survey that assessed the prevalence of HIV and related health indicators in household members aged 0-64 years old, found the distribution of HIV burden across those aged 50 years and above at 13%, which is approximately 280,000 based on new total estimates of 1.9 million persons living with HIV in Nigeria. Based on the NAIIS, gender disaggregation statistics showed that prevalence was highest among females aged 35-39 years at 3.3%, and the highest among males age 50-54 years at 2.3%. A cross-sectional study at a large treatment facility, reported that 10% of the studied population were aged 51 to 60 years, while 0.6% were >60 years. This pool will grow significantly as many ART patients are expected to cross the 50-years baseline, given the efficacy of ART and the current global drive to expand access to treatment and end HIV/AIDS by 2030.
Information on the geriatric population living with HIV in Nigeria is sparse and a systematic description of the HIV geriatric cohort is required to change this. The early and widely recognized impact of AIDS on the elderly was the phenomenon of AIDS orphans— children who lost at least a parent as a result of HIV-related mortality. The report Children on the Brink: 2002 indicates that in 2001, there were 38 million orphans in Africa, 11 million of whom were attributable to AIDS mortality. It predicted that in 2010, 42 million orphans will be in Africa, 20 million of whom will be the result of AIDS mortality. Since formal social security systems do not exist in most sub-Saharan African countries, the elderly largely bear the burden of taking care of the orphans, which compromises their health.
HIV-infection and attendant antiretroviral (ARV) treatment complicate elderly health. AIDS has a disproportionate impact on the health of the elderly compared with the younger adults. Opportunistic infections (OIs) such as pneumocystis pneumonia, extra-pulmonary tuberculosis, and candidiasis have been reported in the elderly. Both HIV and aging synergistically decrease function of B and T-cell lymphocytes which compromises the host’s immunity leading to more OIs. Also, HIV-infection independently creates metabolic abnormalities[14,15] and the toxicities of ARVs and certain drugs used for OIs, create a wide range of diseases including, type 2 diabetes mellitus, myocardial infarction (MI) and atherosclerotic cardiovascular disease[16,17]. In 2016, a Médecins Sans Frontières (MSF) multi-national study reported a higher risk of death among HIV infected people who were aged 50 years and above. Furthermore, age is a risk factor for cardiometabolic disorders; thus, older adults are likely to bear a dual burden of HIV and cardio-metabolic abnormalities, which is on the rise in sub-Saharan Africa.
Nigeria’s HIV-infected elderly face significant challenges due to age, inadequate health care, low social security and a dwindling economy. Although this context necessitates a concerted focus on the elderly, there is no structured care for them. Several reasons contribute to this; earlier studies projected HIV/AIDS prevalence and transmission as a youth issue, this has inadvertently omitted elderly-care in the HIV-control program design. Being elderly is associated with sustaining risky behaviour like less condom use, higher preference for multiple sexual partners and wife inheritance, which predisposes to new infections[21,22].
It is therefore critical to establish a HIV geriatric cohort in Nigeria to provide evidence to add life to years, improve quality of life and outcomes of older adults living with HIV. In this paper, we described data collected on sociodemographic and clinical data from older HIV positive clients from the inception of Nigeria’s national HIV program, and we plan to longitudinally study this cohort with the aim of designing and implementing intervention programs that would improve better health outcomes.
Which cohorts contribute to the collaboration?
The treatment and prevention of HIV/AIDS in Nigeria is coordinated by the National Agency for the Control of AIDS (NACA) – an agency of the Federal Ministry of Health (FMOH). The United States of America’s Government (USG) since 2006, through its Presidents Emergency Plan for AIDS Relief (PEPFAR), supported Nigeria’s free access ART program. Four major implementing partners (IPs) directly cover the treatment program across all of Nigeria’s six geopolitical regions in partnership with health facilities under the general supervision of the US agencies and NACA.
These IPs provide technical support for HIV treatment in most Nigerian states, they include: the Institute of Human Virology Nigeria (IHVN) covering the Federal Capital Territory (FCT) and 4 States (Kano, Katsina and Nassarawa); FHI360 covering 12 States (Adamawa, Akwa Ibom, Anambra, Bauchi, Bayelsa, Borno, Cross River, Edo, Jigawa, Lagos, Rivers and Yobe); APIN Public Health Initiative in Nigeria (APIN) covering 8 States (Lagos, Ogun, Osun, Ekiti, Ondo, Oyo, Plateau and Benue); and Catholic Caritas Foundation of Nigeria (CCFNG) covering 4 States (Delta, Ebonyi, Enugu and Imo). These IPs use a nationally standardized method of data collection and schedule monthly follow-up visits for their patients. This cohort is the first to be set-up to pool geriatric data from these IPs. Furthermore, to the best of our knowledge, no study has described Nigeria’s nationwide geriatric HIV positive population using combined data from these IPs. Definition of terms
Older age: The statistical cut-off for assessing old age varies. Rather than artificially categorizing life into stages such as middle age or old age, it assumes we age from birth. Nevertheless, for statistical purposes, it is often necessary to divide populations into age groups. The analyses the World Health Organization (WHO) uses generally applies 60 years and over as a statistical cut-off. However, some analyses refer to populations of different ages such as ≥ 50 years, ≥ 65 years or ≥ 80 years. In this study, we adopted ≥50 years as our cut-off for old age. This assumption is based on Nigeria’s population life expectancy from birth (2016) which was 54 years [men (55years); women (56years)]. Participants who are ≥50 years at time of testing positive to HIV will be classified as ‘older adults’, ‘elderly’ or ‘geriatrics’.
WHO stage 3 and 4: The diseases defined as WHO stage 3 and 4 in this study are presented in Table 2.2 (pages 28 to 29) of the National Guidelines for HIV Prevention Treatment and Care (2016).
Who is in the cohort?
The USG, through PEPFAR, funded the free access program through its agencies: the Centers for Disease Control and Prevention (CDC), United States Agency for International Development (USAID) and Department of Defense (DoD). IPs with affiliations to US institutions were recruited with the responsibility of treating and preventing HIV/AIDS under the direct supervision of these US agencies. The major IPs, which included IHVN, FHI360, APIN and CCFNG, work with health facilities selected from all of Nigeria’s six geopolitical regions, under which states are grouped, to provide treatment and laboratory services to PLHIV. These IPs manage a network of health facilities in the states assigned to them by NACA and the US agencies. Each IP maintains a treatment database generated from the health facilities under its purview.