What next for ageing HIV population?

The Ministry of Health will have an opportunity to improve on its policies in the fight against HIV in the face of a new report indicating that while the number of new infections has plummeted, the prevalence rate in key cohorts is rising.

The preliminary Kenya Population-based HIV Impact Assessment (KENPHIA) 2018 report, released yesterday points to an ageing HIV-positive population, a fact that might call for the government to review the support services given to people living with HIV.
Prevalence in the age groups from 40-59 years are between 7.5 percent and 9.4 percent, higher than all age categories under 40. Experts say this is majorly a consequence of the success of an aggressive antiretroviral therapy campaign that is enabling HIV positive people to live longer.

Many people in this category are getting weaker and less economically active and thus are increasingly in need of a broader health and nutrition support framework that goes beyond the HIV medicine offered by the government, if the treatment is to continue being effective.

“It is the responsibility of government to make sure that everyone who is infected lives their full life. It might be expensive but it is something that has to be done especially after investing in these people for decades,” says Dr Peter Cherutich, principal investigator at the Ministry of Health who led the KENPHIA study.

He notes that the number of older people living with HIV will continue to grow and hence the need to come in early with policies that address that fact.

Erick Okioma, a 58-year-old resident of Nyalenda in Kisumu City, knows just too well the different shades of life with HIV as a young person and as an older person. He knew his status and started treatment in 2003, two years after he was laid off from public service. Despite the hard economic times, he started the new phase of life positively with the help of relatives. He went back to school then dedicated all his time and energy to advocacy. Sixteen years later, he feels the journey is no longer as bearable as it was back then. “It was particularly bad when I lost my wife in 2017. I forgot to take my medicine several times because I had no one to remind me and my viral count shot up,” he says, adding that he has also felt lonely most of the time since their four children are all grown and spend most of the time away from home. But he realised he wasn’t badly off after all when he got to interact with others like him. There are people who can no longer afford food but are supposed to be on medication, others are also having the long-term use of the ARVs affecting their system and some are depressed,” he says.

They have formed a group, HIV50+, to agitate for the interests of those that they feel the current policies and practices have ignored.

“At this age the set of needs one has are totally different from that of many years ago when one got infected,” says Nelson Otuoma, the executive director of the Network for the Empowerment of People Living with HIV in Kenya (NEPHAK).

Dr Cherutich adds that apart from continuing to support older people living with HIV to handle challenges attendant to age, older people generally should be studied closely to identify any new patterns of new HIV infection for quick and adequate response.

An effective treatment programme has also led to many cases of viral load suppression across the country. Persons living with HIV who achieve viral load suppression have a very low risk of transmitting the virus. Machakos County leads with a viral suppression prevalence of 84 percent among 25 counties with an HIV prevalence greater than 2.2 percent. It is followed by Homa Bay with 83.8 percent and Kisumu (83 percent).

A big majority of people in this emerging critical category are females fed in from younger population categories where infection rates are high. Women are more likely to be infected, get tested and seek treatment and thus live longer with the virus.
The government will have to find out the reasons behind this divergence in response to their programmes and consider redesigning its campaigns and services.

The share of the women population aged 20-34 years living with HIV is three times that of men in the same category, according to the KENPHIA report. This is a highly sexually active category and has traditionally been the highest contributors to new infections.

This is one part of this most recent comprehensive data that blots the big gains such as a drop in the annual national new infections from 106,000 in 2012 to 36,000 and greater access to services.

While there has been slow progress in reducing HIV prevalence among women age 20-29 years, the 30-34 category has delivered the worst results of all cohorts. Prevalence among women at the top of the youth bracket has risen from 6.6 percent in 2012 when they tied with men to 9.5 percent in 2018 when the share of men in that category infected with the virus had dropped by more than half to 3.2 percent.

Higher HIV cases among women is typical of all countries with a high prevalence of the virus and the trend has been linked to the fact that women contract the virus a lot easier than men due to the natural uniqueness of their reproductive organs.

A possible major contributor to a significant drop in incidence among men is the voluntary male medical circumcision (VMMC) campaign which the government has intensified in the past few years. In communities that are traditionally non-circumcising, the adoption of this practice, which medical experts say reduces the risk of acquiring HIV heterosexually by 60-66 percent, may have played a role in lowering the infection rate. The study found that HIV prevalence among uncircumcised men (10.3 percent) was four times higher than in circumcised men (2.5 percent). Prevalence of VMMC was highest in Homa Bay and Siaya (56 percent) among culturally non-circumcising communities.

Dr Cherutich points out that the contribution of VMMC in lowering the rate of new infections in men is almost instant but it takes a long time before such a lower infection rate in men contributes to a decline in the infection rate among women in the same population even by a small margin.

The report indicates that the country is close to achieving the ‘90:90:90’ 2020 goals set by the United Nations HIV/AIDS body, UNAIDS. So far, 80 percent of HIV- positive Kenyans know their status, 96 percent are on treatment and 90 percent have achieved viral suppression.

Only 73 percent of men infected with the virus know their status, compared to 83 percent of the women. Since women are mandatorily tested when they deliver in hospitals and generally have health-seeking tendencies, they have been a lot easier to reach than men with testing campaign and services.

“Bring us the men,” remarked Dr Aberta Mirambeau, from the Centers for Disease Control during a joint-partner briefing with the media on Wednesday.

According to Dr Cherutich, ending HIV in Kenya has a simple formula – a combination of viral suppression and prevention of new infections.

“But it all starts with testing and diagnosis,” he adds.