Although older adults in Uganda showed a high regard for the importance of antiretroviral treatment, structural factors such as wait times and ageism still provide barriers to adherence.
How do older populations (over 50) respond to challenges around antiretroviral treatment (ART) access and adherence compared to their younger counterparts?
Until now, this information was not well known in the African context. In a qualitative study of 40 adults aged 50 to 96 years and living with HIV in rural Uganda, researchers examined barriers and facilitators to ART adherence and access. They discovered that these were comparable to the concerns of younger people outlined in other studies, but older populations had more pressing concerns around non-HIV related health issues.
The cohort consisted mostly of older adults already on ART (n = 26), and some who were waiting to start treatment (n = 14). While test-and-treat is the official policy in Uganda, roll-out has been slow, mainly due to issues around drug procurement. The median age of the group was 62, and most (55%) of the respondents were male.
The researchers used the Andersen Behavioral Model (ABM) of Health Service Use to provide a theoretical framework for understanding factors relating to access and adherence. Results are organised around seven ‘domains’, which include: patient factors (predisposing, enabling, perceived need), healthcare environment factors (system, clinic, provider), and external environment factors.
Via in-depth interviews, respondents then identified 21 primary barriers/facilitators to ART access (the ability and motivation to acquire their antiretroviral medications) and adherence (the ability and motivation to take treatment every day). Of these, nine were overlapping barriers/facilitators for both access ART and the ability and motivation to adhere to treatment on a daily basis, six were related to access and six were mainly discussed in connection to adherence.
The primary ART access concerns of this cohort were transportation, mobility, waiting times at the clinic, healthcare workers’ disregard, and lack of appointment times.
Uganda operates a first-come first-serve policy at most health clinics which presents a challenge for older people who may get uncomfortable waiting for long periods in one place. Simply getting to the clinic because of age-related ailments was also flagged, as well as the cost of transportation, as older people in Uganda do not receive social benefits. They also remarked that they worried about ageism and the fact that HIV is considered a young person’s disease, meaning they felt the health clinic wasn’t for them.
ART adherence was very good in this cohort – better than expected, according to the authors. Here, older populations benefitted from higher levels of health literacy, reminder strategies, and the view that ART was life-saving, which contributed to improved adherence. They enjoyed communicating about ART with their loved ones, and putting reminder systems in place. They also lived through periods where many around them may have died from an AIDS-related illnesses, so they had higher regard for the importance of ART adherence.
Barriers to adherence included alcohol use, travel and a sense of the need for additional counselling. Those who had no family were exponentially impacted by a sense of loneliness and a wondering what there was to live for, which affected their attitudes towards sticking to a drug-taking regime.
Most of the factors raised, however, related both to access and adherence. The analysis highlighted key barriers including food and water insecurity, stigma, depression, health beliefs, symptoms and co-morbidities. We know from previous studies that co-morbidities and depression make it harder to self-manage illness, while age-related stigma and other factors make people feel marginalised and less likely to adhere to treatment.
As people age, dealing with illness becomes more complex, mainly because of multiple co-occurring morbidities – patients themselves find it difficult to assess which symptoms relate to age, and which relate to HIV.
The authors concluded: “The interconnections between ART access and adherence are many, as is evidenced by the number of themes that related to both aspects of HIV care. The interrelatedness stems from economic, cultural and personal factors that affect both the ability and desire to access ART and the ability and desire to adhere to ART on a daily basis.”
They emphasised the growing need to manage non-communicable diseases (NCDs), a growing burden in sub-Saharan Africa, and integrating management of NCDs into HIV care, as effective, large-scale treatment programmes mean more people are growing old with ART.