Joint memorandum submitted by HelpAge
International and Help the Aged
1. INTRODUCTION
1.1 HelpAge International (HAI) and Help
The Aged (HtA) welcome opportunity to provide evidence to the
International Development Committee (IDC) on HIV and AIDS: marginalised
groups and emerging epidemics.
1.2 The combined experience of our organisations
in international development goes back over 40 years. HtA was
founded in 1961 specifically to meet the needs of older people
displaced by disasters and war in central Europe and Africa. Today,
the HelpAge International network works with and for disadvantaged
older people worldwide to achieve a lasting improvement in the
quality of their lives. HelpAge International has been gathering
evidence on the impact of AIDS on older people through programmes
and research. Together we continue to ensure older people are
not forgotten in development and aid programmes.
1.3 In offering evidence to the IDC we have
chosen to focus our response on the issue of the provision of
treatment, care and support to older people in developing countries.
1.4 We would welcome the opportunity to
provide further information to the Committee if this would be
of interest.
2. HIV AND AIDS:
MARGINALISED GROUPS
AND EMERGING
EPIDEMICS
2.1 Many women and men over the age of 50
are sexually active and some inject drugs. They are therefore
at risk of contracting HIV in the same way as those under 50 through
sex and non-sterile equipment (whether through lack of universal
precautions or for injecting drugs). However, their needs in terms
of prevention programmes, treatment, and care and support may
be different. The estimated 2.8 million people over 50 living
with HIV require care and treatment services tailored to their
specific needs, as current mainstream HIV services are failing
to reach the marginalised majority.
2.2 The world is ageing fast with overall
global average life expectancy increasing. Currently one in 12
people in developing countries are over 60 and this will increase
to one in five by 2050. In countries where AIDS has caused average
life expectancy to decline, this averaged statistic masks the
realities and existence of millions of older people. Additionally,
effective treatments are prolonging the lives of those who were
infected at younger ages so that the share of HIV positive persons
who are 50 and older is increasing substantially.
2.3 There is a lack of data and evidence
on people over 50 affected by HIV and AIDS. Until recently, prevalence
data was collected internationally only for people aged 15-49,
ie those considered to be of reproductive age. But susceptibility
to HIV infection continues beyond age 50. This exclusion of people
over 50 from prevalence data has led policy makers and programme
implementers to assume that women and men over 50 are not sexually
active and/or not at risk of infection through sex or other modes
of transmission. The subsequent lack of data and evidence on people
over 50 has resulted in little emphasis by national AIDS councils,
governments, donors and civil society in influencing national
policies and practice to be responsive to people over 50 who are
susceptible to infection or who are living with HIV.
2.4 The lack of information and prevention
programmes targeted to older people about HIV transmission has
led older women and men to also assume that they are not susceptible
to infection. In parts of Latin America many older women and men
believe the sole function of condoms is contraceptive rather than
for disease prevention and control, so as they age older people
who do not feel at risk of pregnancy are much less likely to use
condoms. Free condom distribution programmes are often not accessible
to older people, either because stigma prevents clinicians from
offering condoms and older people from asking for them, or because
the targeting of such initiatives at younger people can have the
unintended consequence of causing older people to think they are
not entitled to free protection.
2.5 Beyond prevention, older people face
numerous barriers to accessing testing and treatment services.
Large geographical distances between services can be insurmountable
to many older people who have reduced incomes on retirement or
reduced mobility as they age. For example, the State HIV and AIDS
programme of Amazonas, Brasil, is acutely aware that its municipality
(the size of England and the largest in the world) is a vast territory
which limits the ability to provide full coverage of services.
A person may travel three or four days to reach the state capital
of Manaus to pick up their medications and return to their village
only to have to return in 15 days to collect more Anti Retrovirals
(ARVs). For many older people this kind of journey is simply unaffordable
or too time-consuming to make. In sub-Saharan Africa where, in
severely affected areas, up to 60% of orphaned or vulnerable children
are being cared for by grandparents, these primary carers cannot
spend extended lengths of time away from their home, nor can they
afford to spend scarce financial resources on transport to reach
testing and treatment services. Many older women are particularly
concerned about the risk of breached confidentiality in regard
to Voluntary Ccounselling and Testing (VCT) which has deterred
them from seeking testing.
Assuming that older people reach services, there
remains a number of reasons why medical practitioners may be reluctant
to test older people for HIV infection. Experience from the USA
shows that persons aged 50 and over may not be promptly tested
for HIV following the onset of HIV-related illnesses, because
clinicians are less likely to consider HIV infection, reluctant
to ask older patients about their sexuality, and more like to
mistake symptoms for other age-related conditions. Many opportunistic
infections that develop in a person with HIV that are often used
by medical staff to determine if the patient may be HIV positive,
such as thrush, are often common in older people. This age discrimination
is exacerbated by the fact that HIV-related illnesses mimic other
diseases associated with ageing, such as Alzheimer's. In addition,
people over 50 may respond differently to drug therapies than
younger people. Rather than invest in research to tailor therapies,
older people are often excluded from clinical drug trials.
2.6 Where ARVs have been made available,
it is important to note that they have worked better to lower
the viral loads and reconstruct the immune system in younger populations
than they have in older populations. For this reason when ARVs
are scarce, and therefore rationed, access to them may be prioritised
for younger people. Long term ARV use has shown a higher probability
in various studies to kidney failure, heart disease, and liver
damage in people over 50 living with HIV than in older people
who are not HIV positive in the global North. There has been only
limited analysis or research into long-term effects of ARV therapies
in older populations in resource-poor societies.
2.7 Many governments now recognise that
the world is ageing. Alongside this there have been some recent
improvements in the recognition of older people's susceptibility
to HIV infection and the increasing number of older people living
with HIV. Most notably there has been a change in data collection
policy by UNAIDS. In the 2006 Global AIDS Report, UNAIDS states
that it no longer excludes people aged 50 and over in their nominal
prevalence statistics. However, prevalence rates will continue
to be provided using only age 15-49 age range for comparison across
countries. According to UNAIDS the number of people who are living
with HIV and who are over 50 is estimated at 2.8 million. In addition
to nascent improvements in data collection there has been an increase
in publicity in major media, particularly in the USA. However,
much of its focus has been on the USA context rather than internationally.
Older people and HIV infection issues in many developing countries
remain under-recognised.
2.8 Thanks to demographic ageing, older
people's issues are necessarily gaining momentum globally and
it is vital that both the ageing and HIV agendas are brought together
to respond more appropriately to older people who are susceptible
to HIV infection or are living with HIV. A more inclusive approach
to HIV and older people is required.
2.9 Drawing the International Development
Select Committee members' attention to the evidence presented
above HelpAge International and Help the Aged make the following
recommendations that the International Development Committee:
— Strongly recommends that UK
Department for International Development ensure that the concerns
and rights of people over 50 are included and addressed in their
own policies and practices and in those of the partners that they
fund.
— Strongly recommends that the
UK Department for International Development more consistently
promotes and works in partnership with governments, researchers
and the development community to ensure that HIV prevalence data
on people over 50 is collected and disaggregated at national and
international level by age and gender to enable policy makers
and programme developers to design interventions that focus on
improving responses for older people.
— Strongly recommends that the
UK Department for International Development supports and advocates
for research into older people and treatment issues, and for introducing
appropriate and relevant training for medical staff to help them
raise sexual and HIV issues with their older patients.
— Strongly recommends that the
UK Department for International Development encourages national
programmes, civil society and international donors alike to promote
an inclusive approach towards older people in national HIV and
AIDS programmes.
October 2006
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