Leaving no one behind: Identifying approaches to improving HIV treatment outcomes among older Ugandans

撒哈拉以南非洲（SSA）的艾滋病毒感染者人数正在增加，因为人们因获得治疗的机会增加而寿命延长。具体来说，50岁以上的艾滋病毒感染者人数预计将从2011年的310万人增加到2040年的910万人。促进老年人获得抗逆转录病毒疗法（ART）并使他们有能力坚持治疗是他们自身健康的关键，遵循“治疗即预防”模式也是防止艾滋病毒在更广泛人群中传播的关键。老年人在很大程度上被预防界所忽视，因为重点一直放在生殖健康、母婴传播和已知艾滋病毒发病率高的年轻人群上。还有一种年龄歧视的误解，认为老年人性生活不活跃。成年人进入老年后性生活仍很活跃，性活动的停止通常是由于身体健康问题和/或找不到性伴侣，老年妇女尤其如此。对美国艾滋病毒阳性老年人的研究发现，他们也保持着性活跃，但超过40%的人不经常使用避孕套；在非洲的研究也出现了类似的结果。获得抗逆转录病毒治疗可以保护她们自身的健康并降低她们的传染性。很少有研究调查老年人获得艾滋病毒治疗和坚持治疗的障碍，而改善抗逆转录病毒治疗的获得和坚持治疗的干预措施也没有专门针对老年人。乌干达的这个项目将提供证据，以解决在南撒哈拉地区老年人获取和坚持抗逆转录病毒治疗方面存在的障碍方面的知识差距。目前尚不清楚老年人群获得和坚持抗逆转录病毒治疗的障碍和促进因素是否与年轻人群相同，或者对其他人群有效的社会干预措施是否足以满足老年人的需求。老年人在社会保障区内获得其他保健服务的障碍包括：高贫困率限制了用于交通和护理的资金；multi-morbidity;对老年人的歧视;医疗服务提供者对老年人的需求了解甚少。社会孤立和与艾滋病毒有关的耻辱进一步影响了他们的福祉。该项目将是第一个制定量身定制的多管齐下的社会干预措施的项目，通过解决个人、社区和卫生系统各级的需求，确定并解决非洲老年人在获得和坚持抗逆转录病毒治疗方面的障碍。在这个项目中，我们将制定和完善多管齐下的社会干预措施，以改善乌干达老年人的获取、坚持和福祉。该项目的具体目标是：(1)通过与老年人、社区领导人和卫生保健工作者的访谈，确定老年人获得和坚持抗逆转录病毒治疗的障碍和促进因素。（2a）根据社区和老年人的观点制定一项干预措施，改善老年人获得和坚持治疗的机会；（2b）建立变革理论，即需要评估变革的预期因素以及干预措施，以解释干预措施是如何起作用的。(3)通过收集潜在客户、社区成员和卫生保健提供者对干预潜力、设计和理想实施方式的看法，完善干预措施。这项工作将有助于设计一项未来的随机试验，该试验将正式评估干预措施在改善获得治疗和坚持治疗以及减少乌干达老年艾滋病毒感染者的社会孤立方面的有效性。

The number of people living with HIV in sub-Saharan Africa (SSA) is increasing, as people live longer due to increased access to treatment. Specifically the number of people living with HIV who are aged 50 years or older is predicted to increase from 3.1 million people in 2011 to 9.1 million in 2040. Facilitating older people's access to anti-retroviral therapy (ART) and enabling their ability to adhere to their treatment is key for their own health, and following a 'treatment as prevention' model it is also key to preventing the spread of HIV into the wider population.Older adults have been largely neglected by the prevention community, because the focus has been on reproductive health, mother-to-child transmission, and younger populations where known HIV incidence is high. There is also an ageist driven myth that older adults are not sexually active. Adults remain sexually active well into old age, with the cessation of sexual activity typically resulting from physical health problems and/or the unavailability of a sexual partner which is particularly the case among older women. Studies of HIV-positive older adults in the U.S. find they too remain sexually active, but upwards of 40% do not use condoms regularly; similar results are emerging from research in Africa. Access to ART can protect their own health and reduce their infectivity. Few studies have examined the barriers for older persons to access treatment for HIV, and to adhere to the treatment, and interventions to improve ART access and adherence have not specifically focused on older adults. This project in Uganda will contribute evidence to address a gap in knowledge on older persons' barriers to ART access and adherence in SSA.It is not clear whether barriers and facilitators to ART access and adherence would be the same for older populations as younger populations, or if social interventions that have worked well for other populations would sufficiently address older adults' needs. Older adults' barriers to other health care services in SSA include high rates of poverty limiting money for transport and care; multi-morbidity; ageism; and little understanding among health providers of older persons' needs. Their wellbeing is further implicated by social isolation and HIV-related stigma. This project will be the first to develop a tailored multi-pronged social intervention that identifies and addresses older Africans' barriers to ART access and adherence by addressing needs at the individual, community and health system levels.In this project, we will develop and refine a multi-pronged social intervention to improve access, adherence and wellbeing among older Ugandans. The specific aims of the project are to: (1) Use interviews with older adults, community leaders and health care workers to identify barriers and facilitators to older adults' ART access and adherence. (2a) Develop an intervention that will improve older adults' access and adherence to treatment based on community and older people's perspectives; (2b) Establish a theory of change, i.e., expected factors that will need to be evaluated for change along with the intervention to explain how the intervention works. (3) Refine the intervention by collecting potential clients', community members', and health care providers' perspectives on the intervention's potential, design and the ideal delivery method.This work will help design a future randomized trial which will formally evaluate how effective the intervention is in improving access and adherence to treatment, as well as reducing social isolation among older people living with HIV in Uganda.