original article Invecchiare con HIV in Ghana: un’analisi degli over 50. Ageing with HIV in Ghana: an analysis of the age group 50 years plus. Nicole Stoller1,2, Barnabas Owusu1, Naa Ashiley Vanderpuye-Donton1 1 West Africa AIDS Foundation / International Health Care Center, Accra, Ghana 2 University of Applied Sciences and Arts Northwestern Switzerland, School of Applied Psychology, Olten, Switzerland Corresponding author: Riassunto Abstract Informazioni sull’HIV nei gruppi di età superiori ai 50 anni Data on HIV amongst the age group 50 years and above Nicole Stoller sono relativamente scarse in molti paesi, compresa l’Africa are relatively poor in many countries, including sub-Saharan West Africa AIDS sub-sahariana. Scopo principale di questo studio è quello di Africa. The main goal of this study was to provide a set Foundation Plot 650, Haatso Ecomog descrivere le caratteristiche di un insieme di persone anzia- of baseline characteristics of older people living with HIV Ave, Haatso ne che vivono con HIV (PLHIV). Inoltre, lo studio ha cerca- (PLHIV). Furthermore, the study sought to identify whether Accra, Ghana to di identificare se le caratteristiche analizzate rivelassero the analysed characteristics revealed gender disparities. eventuali disparità di genere. A retrospective analysis of patient data at a private HIV clinic nicole_stoller@hotmail.com É stata effettuata un’analisi retrospettiva dei dati dei pazien- in Ghana was performed. Demographic, behavioural and ti di una clinica privata in Ghana. Sono stati selezionate le clinical characteristics of 282 PLHIV aged 50 years or older at Keywords: informazioni demografiche, comportamentali e cliniche di their most recent consultation between 2015 and 2019 were ageing, HIV, stigma, 282 PLHIV, che all’ultima consultazione avessero 50 o più selected. Descriptive and inferential statistics were used for disclosure, Africa anni. I dati sono stati raccolti tra il 2015 e il 2019. Per l’analisi analysis. Conflict of interest: None sono state usate statistiche descrittive e inferenziali. The median age was 56 years, and 57% (162/282) of subjects L’età mediana era di 56 anni, e il 57% dei soggetti erano don- were female. Sexual activity was confirmed by 44.2% JHA 2021; 6(4): 59-65 ne (162/282). L’attività sessuale era confermata dal 44.2% (111/251) of subjects, more frequently by men. Nearly all (111/251) dei soggetti, più frequentemente dagli uomi- patients (97.3%, 249/256) were on antiretroviral treatment, DOI: 10.19198/JHA31522 ni. Quasi tutti i pazienti (97.3%, 249/256) erano in terapia and 70.2% (172/245) adhered well. Viral suppression with < antiretrovirale, e il 70.2% (172/245) con buona aderenza. 1000 copies/mL was achieved by 63.6% (89/140) of patients, Una carica virale <1000 copie/ml era raggiunta dal 63.6% more frequently by women. Non-disclosure of HIV status was (89/140) dei pazienti, più frequentemente dalle donne. Il reported by 73.5% (191/260) of patients, with more women 73.5% (191/260) dei pazienti, in misura Maggiore le donne, not having disclosed their status. non avevano rivelato il loro stato HIV. Our finding of high non-disclosure rates could indicate that Questa elevata proporzione di persone che non rivelano il stigma and discrimination are amongst one of the biggest loro status HIV può indicare che lo stigma e la discriminazio- challenges for this age group. With regard to the WHO ne sono tra le maggiori sfide per questo gruppo di età. Per “fourth 90” target, further research is needed to learn more quanto riguarda l’obiettivo dell’OMS del “quarto 90”, sono about the health situations and needs of PLHIV aged 50 and necessari ulteriori study sulla situazione e i bisogni sanitari over, especially in a geographical area where specific HIV data dei PLHIV over 50, specialmente in un’area geografica dove are sparse. sono pochi i dati specifici su HIV. Introduction at 8.1 million people diagnosed with HIV worldwide The longevity of people living with HIV (PLHIV) has ri- aged 50 and over (3,4). More than 4 million PLHIV sen since the advent of life-prolonging antiretroviral aged 50 and over live in sub-Saharan Africa (4), a fi- medication (1,2). The number of older PLHIV has in- gure that is expected to rise in the coming years (5). creased steadily in recent years and currently stands However, reporting on HIV data historically ends at 539 original article the age of 49, and information on older PLHIV/AIDS mine whether the characteristics analysed revealed is still relatively poor (1,2). While HIV prevention, gender disparities. intervention programmes and sexuality studies in sub-Saharan Africa have focused mainly on the youn- Material and methods ger adult population aged 15-49, little has been done Setting to understand the sexual behaviour of the population The study was conducted at the International Heal- aged 50 and over (6). Bendavid, Ford and Mills (7) th Care Center, a private ART-accredited health fa- found that people aged 50 years and over show HIV cility in Accra, Ghana, a lower middle-income coun- risk behaviour similar to younger age groups, but it is try in West Africa. The community outpatient clinic paired with poor HIV awareness and low perception is one opened to the general public with a focus on of their own risk of acquiring HIV. infectious diseases. It has been providing medical Ageing with HIV could lead to various physical chal- care and support to PLHIV since 1999. HIV services lenges, including general age-related comorbidities, are fully integrated into the services of the clinic, such as cardiovascular disease or cancer and organ and in addition to other services, the clinic provides system injuries as a result of HIV infection or the toxi- counselling for patients on issues such as disclosure city of antiretroviral treatment (ART) (8). Regarding of HIV status and therapy adherence. the psychosocial challenges, the impact of stigma and discrimination can be devastating for older PLHIV in Study design and sample sub-Saharan Africa, as they face fears of rejection and A retrospective analysis of routinely collected pa- exclusion from society (9). Moreover, the perceived tient data from electronic medical records was lack of confidentiality of health workers increases the carried out. PLHIV were eligible if they were 50 concerns of PLHIV about stigmatization or involuntary years old or older at their most recent medical disclosure of their HIV status (10,11). consultation at the facility between January 2015 In Ghana, where this analysis was carried out, HIV pre- and June 2019. Both the initial admission and fol- valence in the general population is 1.7%, with preva- low-up appointments were considered medical lence rates in the key population disproportionately consultations. high, such as female sex workers (6.9%) and men who have sex with men (18%) (12). While Ghana is also Ethical considerations confronted with a paucity of accurate HIV data (13), The data analysis of our research originated from specific information about Ghanaian PLHIV belonging an internal project for quality improvement at the to the age group 50 years plus are also sparse. Accor- clinic. The retrospective analysis was based on rou- ding to the Ghana National AIDS Control Programme, tine data without actual physical involvement of there are no accurate data on adherence to ART or clients. Due to the retrospective character of the on the number of patients on ART who have achieved project, consents from the patients were not avai- viral suppression (13). This data is also necessary to lable. All data were de-identified prior to analysis. assess the current status of the UN-AIDS 90-90-90 go- The anonymity of the sample was guaranteed, and als (i.e., by 2020), 90% of people living with HIV know no conclusions could be drawn about the identity their status, 90% who know their status receive su- of any one patient. stained treatment and 90% of those on treatment are virally suppressed (14). Additionally, the expansion of Data source and variables the WHO targets by the “fourth 90”, concerning heal- Routinely collected patient data were exported th-related quality of life, also requires corresponding from the electronic clinical information system. data (15). Therefore, further efforts are needed not The data export was programmed to obtain the la- only to improve baseline data for the general popu- test available data for each variable. The selected lation diagnosed with HIV but also to integrate the 50 variables were divided into demographic, beha- years plus age group into HIV monitoring and repor- vioural and clinical characteristics. Answers such as ting systems (2). unknown or not applicable were treated as missing Therefore, the main objective of this study was to data. The variables had been recorded electroni- identify a set of baseline characteristics in older PLHIV. cally by trained physicians, nurses and laboratory As a secondary objective, the study sought to deter- technicians. For obtaining viral load results, blood 640 original article samples were taken in-house and routinely sent to Table 1. Demographic characteristics of people living with HIV aged 50 years and over at a teaching hospital in Accra for analysis, and the re- a Ghanaian HIV clinic, 2015 – 2019. sults were sent back to the health facility. Total Female Male n (%) n (%) n (%) p-value Data analysis 282 (100) 162 (57) 120 (43) We described frequencies of the selected variables, a which were stratified by gender. To test the associa- Median age (IQR) 56 (52-61) 56 (53-62) 55 (52-59) .069 tions between gender and the nominal variables, Age groups 282 162 120 we used Pearson's chi-square test and Fisher’s 50-59 199 (70.6) 107 (66.0) 92 (76.7) .057a exact test if the assumptions of the chi-square test 60-69 65 (23.0) 43 (26.5) 22 (18.3) were not reached. To compare the continuous and 70-79 14 (5.0) 10 (6.2) 4 (3.3) ordinal variables between women and men, we used the non-parametric Mann-Whitney test. We ≥80 4 (1.4) 2 (1.2) 2 (1.7) used an alpha level of 0.05 for all statistical tests. Marital status 220 129 91 After the chi-square test detected significant asso- Married/widowed 147 (66.8) 78 (60.5) 69 (75.8) .020b ciations, we evaluated the strength of the associa- Single/separated/divorced 73 (33.2) 51 (39.5) 22 (24.2) tion using Cramer's V. The effect size Cramer's V can Educational level 188 115 73 reach a maximum of one, with values of 0.10 for small, 0.30 for medium and 0.50 for large effects finished secondary level 64 (34.0) 25 (21.7) 39 (53.4) .000 b (16). Statistical analysis was performed using Mi- not finished secondary level 124 (66.0) 90 (78.3) 34 (46.6) crosoft Office Excel 2016 and IBM® SPSS Statistics, Religion 240 142 98 version 25. Christian 225 (93.8) 133 (93.7) 92 (93.9) .999c Results Muslim 12 (5.0) 7 (4.9) 5 (5.1) We identified 286 PLHIV aged 50 years or older at Traditional 1 (0.4) 1 (0.7) 0 (0.0) their most recent medical consultation at the Inter- None 2 (0.8) 1 (0.7) 1 (1.0) national Health Care Center between January 2015 aMann-Whitney test, bPearson’s chi-square test, cFisher´s exact test. All values are n (%) or median (IQR). and June 2019. Four cases were excluded due to a lack of relevant data. A total of 282 cases was fi- nally included in the study. Since complete medical The association between education and gender records were not available for all cases, the actual was significant with a moderate effect (χ2 (1, N = numbers for each variable are shown below. All 188) = 19.97, p < 0.001, V = 0.33). All results of de- gender-specific results can be seen in Tables 1-3. mographic characteristics are shown in Table 1. Demographic characteristics Behavioural characteristics The sample of patients consisted of 57% women Current sexual activity (not further specified) was (162/282) and 43% men (120/282). The age of confirmed by 44.2% of patients, and the frequen- the patients ranged from 50 to 91 years, with a cies differed significantly between gender (χ2 (1, N median age of 56 (IQR, 52-61). The majority of = 251) = 45.02, p < 0.001). The effect was moderate patients (199/282, 70.6%) were in the 50-59 age (V = 0.42). Men were more likely than women to group. More than half of the patients were married report sexual activity (69.2% vs. 26.5%). Occasio- (113/220, 51.4%). Men were more likely than wo- nal use of condoms (sometimes) was reported by men to be married or widowed (75.8% vs. 60.5%). 67.1% (96/143) of the patient group. Good adhe- The association between marital status and gender rence to ART with zero pills missed in the last 3 days was significant with a small effect (χ2 (1, N = 220) = was reported by 70.2% (172/245) of patients. Near- 5.68, p = 0.020, V = 0.16). The majority of the sam- ly three-quarters of the patients (191/260, 73.5%) ple group were Christians (225/240, 93.8%), while had not disclosed their HIV status to family, friends 5% (12/240) of the sample group were Muslims. or sexual partners (Figure 1). Women were more Men were more likely than women to have finished likely than men not to have disclosed their HIV sta- secondary level education (53.4% vs. 21.7%). tus (82.9% vs. 60.2%). 6 51 original article Figure 1. Disclosure of HIV status (n=260). Figure 2. Patients on ART (n=256). Table 2. Behavioural characteristics of people living with HIV aged 50 years and over at a Ghana-ian HIV clinic, 2015 – 2019. Total Female Male n (%) n (%) n (%) p-value Sexual activity 251 147 104 Sexually active 111 (44.2) 39 (73.5) 72 (69.2) .000a Not sexually active 140 (55.8) 108 (73.5) 32 (30.8) Figure 3. Viral load on ART (n=140). Condom Use 143 72 71 Always 28 (19.6) 9 (12.5) 19 (26.8) .097b (71.6% vs. 52.5%). The association between viral Sometimes 96 (67.1) 53 (73.6) 43 (60.6) suppression and gender was significant with a small 2 Never 19 (13.3) 10 (13.9) 9 (12.7) effect (χ (1, N = 140) = 5.36, p = 0.022, V = 0.20). Adherence to ART last 3 days 245 145 100 All results of clinical characteristics are shown in Table 3. 0 pill missed 172 (70.2) 103 (71.0) 69 (69.0) .685b 1-2 pills missed 14 (5.7) 9 (6.2) 5 (5.0) Discussion 3-4 pills missed 11 (4.5) 6 (4.1) 5 (5.0) We performed a retrospective analysis of routinely >5 pills missed 48 (19.6) 27 (18.6) 21 (21.0) collected patient data from an outpatient clinic with integrated HIV services in Accra, Ghana. The Disclosure of HIV status 260 152 108 main goal was to provide a set of baseline characte- Disclosed 69 (26.5) 26 (18.6) 43 (39.8) .000a ristics of older PLHIV. Not disclosed 191 (73.5) 126 (82.9) 65 (60.2) Our study sample of 282 PLHIV aged 50 years plus a Pearson’s chi-square test, b Mann-Whitney test. All values are n (%). showed a high proportion of sexually active men (69.2%). This is comparable to the findings of other studies in sub-Saharan Africa. Country reports The relationship between disclosure and gender from this area have shown that, within the gene- was significant, however, with only a small effect (χ2 ral population, about 74% of men aged 50 years (1, N = 260) = 16.70, p < 0.001, V = 0.25). All results and over are sexually active and that the majority of behavioural characteristics are shown in Table 2. of them are engaged in high-risk sexual behaviour, such as having multiple sex partners and not using Clinical characteristics condoms (6,17). A study from South Africa also re- Almost half of the patient group were classified as vealed the tendency of elderly men to have mul- WHO clinical stage I (118/264, 44.7%). Nearly all tiple partners, while women accepted the male patients of the sample group with available data promiscuity (18). The study further stated that (249/256, 97.3%), were on ART (Figure 2). Viral both genders blame each other for the spreading load test results were available for 140 patients of HIV/AIDS. Both elderly men and women should who were on ART for at least 6 months. Among be more strongly approached for HIV prevention them, 63.6% (89/140) were virally suppressed with and treatment. Whereas men over 50 years of age < 1000 copies/mL (Figure 3). Women were more are at risk of infection due to unsafe sexual beha- likely than men to have achieved viral suppression viour, women in the subregion are also at high risk 626 original article of acquiring HIV for cultural and physical reasons Table 3. Clinical characteristics of people living with HIV aged 50 years and over at a (9). Gender inequality still results in insufficient ne- Ghanaian HIV clinic, 2015 – 2019. gotiating power for women in marital relationships. Total Female Male Lack of control over decisions or financial resour- n (%) n (%) n (%) p-value ces can prevent them from gaining access to health WHO clinical stage 264 155 109 facilities for HIV testing or treatment (11). Sexually a active women over 50 years of age are at additio- Stage I 118 (44.7) 72 (46.5) 46 (42.2) .422 nal risk of HIV infection from hormonal changes (9). Stage II 66 (25.0) 40 (25.8) 26 (23.9) A thinner postmenopausal vaginal wall promotes, Stage III 67 (25.4) 34 (21.9) 33 (30.3) among other things, tissue injury and thus HIV tran- Stage IV 13 (4.9) 9 (5.8) 4 (3.7) smission during sex (9,19). Patient on ART 256 150 106 More than two-thirds of the patients reported that b they adhered well to ART. Other authors have de- Yes 249 (97.3) 147 (98.0) 102 (96.2) .453 scribed high adherence to ART in the older popu- No 7 (2.7) 3 (2.0) 4 (3.8) lation, suggesting that adherence is the key factor Viral load on ART (min. 6 months) 140 81 59 for older PLHIV when it comes to better virological < 1000 copies/mL 89 (63.6) 58 (71.6) 31 (52.5) .022b responses as compared to that for younger age ≥ 1000 copies/mL 51 (36.4) 23 (28.4) 28 (47.5) groups (20,21). However, it should be noted that a b older people's adherence to treatment may decre- Mann-Whitney test. Pearson’s chi-square test. All values are n (%). ase due to simultaneous suffering from age-related chronic diseases or difficult socioeconomic condi- tions leading to food insecurity or lack of resources In Ghana, the question “Would you buy fresh ve- to transport them to a clinic (22). getables from a shopkeeper or vendor if you knew Furthermore, we found that a high proportion that this person had HIV?” was answered “No” by (73.5%) of women and men living with HIV did not two out of three people in 2014 (12). This persi- disclose their HIV status, neither to family or friends stently strong stigma in society makes it difficult for nor to current sexual partners. This result, which is PLHIV to talk about their infection. In order to pro- more significant amongst women, showcases the mote PLHIV disclosure initiatives, supportive and difficulties PLHIV in Ghana face openly talking about trustworthy framework conditions must be created their status. Unlike our findings, Obermeyer et al. (26). (23) reported disclosure rates of over 74% among In 2016, the WHO Test-and-Treat policy was adop- adults diagnosed with HIV in sub-Saharan Africa ted in Ghana, which made all PLHIV eligible for ART but with strong variations between the countries. regardless of the WHO clinical stage or immunolo- The authors found no clear evidence as to whether gical conditions (13). The most frequently prescri- more men or more women had disclosed their sta- bed first-line ART in our sample were Lamivudine tus. Nevertheless, gender differences have been 150mg / Zidovudine 300mg / Nevirapine 200mg revealed in a study (24) in Ethiopia. Regarding the tablets. The dose for a regimen was Lamivudine reasons for non-disclosure, the authors found that / Zidovudine combined in one pill 450mg twice men were inclined to report that they did not want daily and Nevirapine 400mg twice daily. Nevirapi- to reveal infidelity, while women were more likely ne could be switched with Efavirenz 600mg once to report fear of violence or abandonment. Ojiku- daily. Zidovudine could be switched with Tenofo- tu et al. (25) examined the disclosure behaviour of vir 300mg once daily. It should be mentioned that female PLHIV in Thailand, Brazil and Zambia. The Dolutegravir was only available in Ghana after the predictors for non-disclosure they identified were cut-off date of our sample (i.e. after June 2019). HIV stigma at the community level, depression, sel- Analysis of our sample showed almost complete f-stigma and older age, with similar findings in all coverage of patients on ART (97.3%), while the esti- three geographical areas. The authors, therefore, mated coverage of adult patients in Ghana was at recommended focusing mainly on community in- 35% (12). terventions to reduce stigmatization and discrimi- The high number of treated patients in our sample nation against PLHIV (25). may be the result of consistent implementation of 673 original article the WHO policy in the participating health clinic. tients in all situations, urban and rural (14). This result shows that it is possible to achieve at Our study contains some limitations. The sample least one of the UNAIDS 90-90-90 goals at the is based on one outpatient health facility and may community level. not represent other populations diagnosed with In our data, we had viral load results for 140 cases. HIV. In addition, the method of data extraction Viral suppression, defined as < 1000 copies/mL was from the electronic medical records leads to some achieved for 63.6% of patients. This result amon- restrictions for statistical evaluation, since the data gst our elderly PLHIV, although not at the UN target of a patient case may originate from two or more of 90%, is close to reaching the target, compared follow-up appointments in the clinic. Finally, as a to that of the general adult population with HIV in general limitation, the accuracy of self-reported sub-Saharan Africa, which stands at 29% for viral answers to questions about sexual activity, condom suppression (14). The effect of age on the response use or adherence to treatment may be limited due to ART in this area is so far not well documented to socially desired responses (28). (27). However, as mentioned before, the 50 years Nevertheless, in a geographical area where specific plus PLHIV age group have been characterized with HIV data are sparse, further research is needed to good adherence to treatment. Moreover, several learn more about the situations, needs and chal- studies with older PLHIV on ART reported similar or lenges of the 50 years plus age group. As more even better virological responses of older groups as differentiated information becomes available, he- compared to those of younger age groups (20,21). althcare institutions can further develop patient-o- A finding that requires further investigation is the riented and gender-specific services and optimize moderate amount of available viral load data. Low medical and psychosocial care and support for this availability of viral load results was also stated by growing HIV population. other researchers and appear to be found in most limited-resource countries (27). Testing and moni- Acknowledgements toring of viral load is essential to enable physicians We thank Sandra Opokua for her contribution in to make timely and accurate medical decisions initial data plausibilization and Nadine Schneider about the treatment of their patients with HIV (14). for reviewing the manuscript. We also thank the UNAIDS recommends a combination of centralized team of the International Health Care Clinic and laboratories and point-of-care tools to provide easy West Africa AIDS Foundation for provision of clini- and affordable access to viral load testing for pa- cal knowledge during the study. BIBLIOGRAFIA 1. Brennan-Ing MG, MacPhail C, Seeley J, et al. Global ageing with HIV: Differences between high- and low-resource settings. Innov Ageing 2017; 1: 622. doi:10.1093/geroni/igx004.2185 2. Mahy M, Autenrieth CS, Stanecki K, Wynd S. Increasing trends in HIV prevalence among people aged 50 years and older. AIDS 2014; 28: 453-459 doi:10.1097/QAD.0000000000000479 3. UNAIDS. UNAIDS DATA 2019. Geneva: UNAIDS; 2019. http://www.unaids.org/sites/default/files/media_asset/2019-UNAIDS-data_ en.pdf. Accessed 07 Nov 2021. 4. UNAIDS. AIDSinfo. Geneva: UNAIDS; 2020. http://aidsinfo.unaids.org. Accessed 07 Nov 2021. 5. Hontelez JAC, Tanser FC, Naidu KK, Pillay D, Bärnighausen T. The effect of antiretroviral treatment on health care utilization in rural South Africa: A population-based cohort study. PLoS ONE 2016; 11: e0158015. doi:10.1371/journal.pone.0158015 6. Odimegwu CO, Mutanda N. Covariates of high-risk sexual behaviour of men aged 50 years and above in sub-Saharan Africa. Sahara J 2017; 14: 162-170. doi:10.1080/17290376.2017.1392340 7. Bendavid E, Ford N, Mills EJ. HIV and Africa’s elderly: The problems and possibilities. AIDS 2012; 26: 85-91. doi:10.1097/ QAD.0b013e3283558513 8. Althoff K, Smit M, Reiss P, Justice AC. HIV and ageing: Improving quantity and quality of life. Curr Opin HIV AIDS 2016; 11: 527-536. doi:10.1097/COH.0000000000000305 9. UNAIDS. The Gap Report. Geneva: UNAIDS; 2014. http://files.unaids.org/en/media/unaids/contentassets/documents/ unaidspublication/2014/UNAIDS_Gap_report_en.pdf. Accessed 07 Nov 2021. 10. Adjetey V, Obiri-Yeboah D, Dornoo B. Differentiated service delivery: A qualitative study of people living with HIV and accessing care in a tertiary facility in Ghana. BMC Health Serv Res 2019; 19: 1-7. doi:10.1186/s12913-019-3878-7 684 original article 11. Musheke M, Ntalasha H, Gari S, Mckenzie O, Bond V. A systematic review of qualitative findings on factors enabling and deterring uptake of HIV testing in Sub-Saharan Africa. BMC Public Health 2013; 13: 1-16. doi:1471-2458/13/220 12. UNAIDS. Country factsheets GHANA 2020. HIV and AIDS Estimates. Geneva: UNAIDS; 2020. http://aidsinfo.unaids.org/. Accessed 07 Nov 2021. 13. Ali H, Amoyaw F, Baden D, et al. Ghana’s HIV epidemic and PEPFAR’s contribution to-wards epidemic control. Ghana Med J 2019; 53: 59-62. doi:10.4314/gmj.v53i1.9 14. UNAIDS. 90-90-90: An ambitious treatment target to help end the AIDS epidemic. Geneva: UNAIDS; 2014. http://files.unaids.org/en/ media/unaids/contentassets/documents/unaidspublication/2014/90-90-90_en.pdf. Accessed 07 Nov 2021. 15. Lazarus JV, Safreed-Harmon K, Barton SE, et al. Beyond viral suppression of HIV – the new quality of life frontier. BMC Medicine 2016; 14: 94. doi: 10.1186/s12916-016-0640-4 16. Cohen J. Statistical power analysis for the behavioral sciences. 2 ed. Lawrence Erlbaum Asso-ciates USA 1988. 17. UNAIDS. The Prevention Gap Report. Geneva: UNAIDS; 2016. http://www.unaids.org/sites/default/files/media_asset/2016- prevention-gap-report_en.pdf. Ac-cessed 07 Nov 2021. 18. Lekalakala-Mokgele E. Exploring gender perceptions of risk of HIV infection and related be-haviour among elderly men and women of Ga-Rankuwa, Gauteng Province, South Africa. Sa-hara-J 2016; 13: 88-95. doi:10.1080/17290376.2016.1218790 19. Wessels JM, Felker AM, Dupont HA, Kaushic C. The relationship between sex hormones, the vaginal microbiome and immunity in HIV- 1 susceptibility in women. Dis Model Mech 2018; 11: 1-15. doi:10.1242/dmm.035147. 20. Silverberg MJ, Leyden W, Horberg MA, et al. Older Age and the Response to and Tolerability of Antiretroviral Therapy. Arch Intern Med 2007; 167: 684-691. doi: 10.1001/archinte.167.7.684 21. Wellons MF, Sanders L, Edwards LJ, et al. HIV infection: Treatment outcomes in older and younger adults. J Am Geriatr Soc 2002; 50: 603-607. 22. Newman J, Iriondo-Perez J, Hemingway-Foday J, et al. Older adults accessing HIV care and treatment and adherence in the IeDEA central Africa cohort. AIDS Res Treat 2012; 1-8. doi:10.1155/2012/725713 23. Obermeyer CM, Baijal P, Pegurri E. Facilitating HIV disclosure across diverse settings: A review. Am J Public Health 2011; 101: 1011- 1023. doi:10.2105/ AJPH.2010.300102 24. Deribe K, Woldemichael K, Bernard N, Yakob B. Gender difference in HIV status disclosure among HIV positive service users. East Afr J Public Health 2009; 6: 248-255. 25. Ojikutu BO, Pathak S, Srithanaviboonchai K, et al. Community Cultural Norms, Stigma and Disclosure to Sexual Partners among Women Living with HIV in Thailand, Brazil and Zambia (HPTN 063). PLoS ONE 2016; 11: e0153600. doi:10.1371/journal.pone.0153600. 26. Obiri-Yeboah D, Amoako-Sakyi D, Baidoo I, Adu-Oppong A, Rheinländer T. The ‘Fears’ of Disclosing HIV Status to Sexual Partners: A Mixed Methods Study in a Counseling Setting in Ghana. AIDS Behav 2016; 20: 126-136. doi:10.1007/s10461-015-1022-1 27. Balestre E, Eholie SP, Lokussue A, et al. Effect of age on immunological response in the first year of antiretroviral therapy in HIV-1- infected adults in West Africa. AIDS 2012; 26: 951-957. doi:10.1097/QAD.0b013e3283528ad4 28. Guest G, Bunce A, Johnson L, Akumatey B, Adeokun L. Fear, hope and social desirability bias among women at high risk for HIV in West Africa. J Fam Plann Reprod Heal Care 2005; 33: 285–288. doi:10.1783 /jfp.31.2.285 965