Aging with HIV in Africa: the challenges of living longer

The trend analysis of HIV and other sexually transmitted infections among the elderly aged 50 to 69 years from 1990 to 2030

Background

The HIV and other sexually transmitted infections (STI) excluding HIV among the elderly population urgently require more attention and in-depth study. We aimed to present and predict the worldwide of its burden from 1990 to 2030 using data from the Global Burden of Disease (GBD) study.

Methods

Leveraging the 2019 GBD study, we investigated the average annual percentage change (AAPC) of HIV and other STI in incidence, prevalence, disability-adjusted life years (DALYs), and mortality rates for individuals aged 50-69 across different age groups, genders, sociodemographic index (SDI) regions, and nations. The incidence of STI in the population from 2020 to 2030 was explored by Bayesian age-period-cohort (BAPC) prediction model.

Results

The HIV incidence rate experienced its fastest growth 1990-1992, peaked in 1996, and gradually declined thereafter, with the 2019 rate being lower than that of 1990. The prevalence rate didn't present a sharp turning point. After 2006, its growth rate accelerated. Both DALYs and mortality rates plateaued high between 2002 and 2005, followed by a decline. The decline was steepest from 2005-2012, yet the rate of decrease slowed noticeably from 2012-2019.When segmented by age, HIV was more prevalent among those aged 55-59 and 50-54, with the 50-54 age group witnessing the fastest decline in incidence rates. However, the fastest growth in prevalence rates was seen among the 60-64 and 65-69 age groups. The other STI incidence rate declined from 1990-1996, increased up to 2006, declined until 2015, and then saw a resurgence with accelerated growth thereafter. The prevalence rate showcased varied trends, with a notable increase in the past five years. The highest growth in incidence rate was among the 65-69 age group. We predict that the incidence rate of STI will increase in the future.

Conclusions

Overall, despite the evident decline in incidence, mortality rates, and DALYs, the prevalence of HIV and other STI among the elderly is rising, and both demonstrated significant trend variations across different ages, genders, SDI regions, and nations. Comprehensive sexual health education, clinical care and adjustments in health service strategies based on the evolving trends of HIV and other STI among the elderly are paramount.

Cost-effectiveness of differentiated care models that incorporate economic strengthening for HIV antiretroviral therapy adherence: a systematic review

BACKGROUND

There is some evidence that differentiated service delivery (DSD) models, which use a client-centered approach to simplify and increase access to care, improve clinical outcomes among people living with HIV (PLHIV) in high HIV prevalence countries. Integrating economic strengthening tools (e.g., microcredit, cash transfers, food assistance) within DSD models can help address the poverty-related barriers to HIV antiretroviral therapy (ART). Yet there is minimal evidence of the cost-effectiveness of these types of multilevel care delivery models, which potentially prohibits their wider implementation.

METHODS

Using a qualitative systematic review, this article synthesizes the literature surrounding the cost-effectiveness of differentiated service delivery models that employ economic strengthening initiatives to improve HIV treatment adherence in low- and middle-income countries. We searched three academic databases for randomized controlled trials and observational studies published from January 2000 through March 2024 in Sub-Saharan Africa. The quality of each study was scored using a validated appraisal system.

RESULTS

Eighty-nine full texts were reviewed and 3 met all eligibility criteria. Two of the three included articles were specific to adolescents living with HIV. Economic strengthening opportunities varied by care model, and included developmental savings accounts, microenterprise workshops, and cash and non-cash conditional incentives. The main drivers of programmatic and per-patient costs were ART medications, CD4 cell count testing, and economic strengthening activities.

CONCLUSION

All economic evaluations in this review found that including economic strengthening as part of comprehensive differentiated service delivery was cost-effective at a willingness to pay threshold of at least 2 times the national per capita gross domestic product. Two of the three studies in this review focused on adolescents, suggesting that these types of care models may be especially cost-effective for youth entering adulthood. All studies were from the provider perspective, indicating that additional evidence is needed to inform the potential cost-savings of DSD and economic strengthening interventions to patients and society. Randomized trials testing the effectiveness of DSD models that integrate economic strengthening should place greater emphasis on costing these types of programs to inform the potential for bringing these types of multilevel interventions to scale.

The Social Construction of Aging Among a Clinic-Based Population and Their Healthcare Workers in Zambia

Objectives

We sought to understand the social construction of aging in a clinic-based population, with and without HIV, to address gaps in care for older individuals living with HIV in Zambia.

Methods

Our exploratory qualitative study included 36 in-depth interviews with clinic clients and four focus group discussions with 36 professional and lay healthcare workers providing services to the clients. We identified themes based on social construction theory.

Results

At the individual level, aging was multidimensional, perceived both as an achievement in the HIV era and as a period of cognitive, physical, and economic decline. In social interactions, older individuals were often stereotyped and treated as helpless, poor, and "witches." Those living with HIV faced the additional stigma of being labeled as promiscuous. Some of the participants living without HIV refused to take daily medication for non-communicable diseases to avoid being mistaken for taking antiretroviral therapy for HIV. Older individuals wanted quality healthcare and family support to address the intersectional stigma of aging, poverty, and chronic illness.

Conclusion

Multifaceted interventions are required to combat age-related prejudice, intersectional stigma, and discriminatory practices, particularly for people living with HIV.

Moving forward: Scaling-up the integration of an HIV and hypertension program in Akwa Ibom State, Nigeria

Background

As people living with HIV experience increased life expectancy, there is a growing concern about the burden of comorbid non-communicable diseases, particularly hypertension. This policy brief describes the current policy landscape in Akwa Ibom State, Nigeria, the research activities, and five policy recommendations rooted in an ongoing research study designed to integrate hypertension management into HIV care across primary health centers in the state.

Analysis

The policy brief was developed in four steps: review of existing policies, using the reviewed policies to inform research activities, solicitation of stakeholder recommendations via focus group discussions, and formulation of the resulting five policy recommendations for integrating hypertension management into HIV care programs in Akwa Ibom. The key analysis for this brief emerged from the thematic analyses of stakeholder responses.

Policy Implications

The five policy recommendations for integrating hypertension management in HIV care in Akwa Ibom State, Nigeria are: 1) build capacity by leveraging retired community nurses as mentors; 2) emphasize community engagement; 3) develop consistent training programs on hypertension management for health workers; 4) expand health insurance accessibility; and 5) formally integrate hypertension management into primary healthcare centers in Akwa Ibom State.

Ageing with HIV: challenges and coping mechanisms of older adults 50 years and above living with HIV in Uganda

INTRODUCTION

Globally, adults 50 years and older are an increasing proportion of persons living with HIV (PLHIV), accounting for 16% of the patient group globally. The long-term effects of antiretroviral use are still being discovered and have been associated with several comorbidities; Stigma presents challenges for those in need of services and health care and can significantly affect mental health and treatment adherence. Understanding the experiences and challenges of older PLHIV will inform the development of interventions to improve their care, health, and quality of life, which may help prevent the further spread of HIV. We explored the experiences and challenges of older PLHIV aged 50 years and above.

METHODS

We conducted 40 in-depth interviews with elderly PLHIV aged 50 years and above who had lived with HIV for more than ten years. We also explored the experiences and challenges of ageing with HIV in two hospitals. We analysed the data thematically.

RESULTS

The key themes that emerged included; late diagnosis of HIV, depression and fear at the time of diagnosis, acceptance of close family, stigma from community, polypharmacy, development of comorbidities, financial burden, resilience, and mastery of own care.

CONCLUSION

Older adults experience several challenges, and there is a need to develop special clinics providing appropriate care for the ageing and their social life. Prevention, Early diagnosis and appropriate treatment of HIV, and appropriate geriatric care are essential for the well-being of elderly PLHIV.

The Impact of Human Immunodeficiency Virus and Menopause on Bone Mineral Density: A Longitudinal Study of Urban-Dwelling South African Women

An estimated 25% of South African women live with human immunodeficiency virus (HIV). Antiretroviral therapy roll-out has improved life expectancy, so many more women now reach menopause. We aimed to quantify changes in bone mineral density (BMD) during the menopausal transition in urban-dwelling South African women with and without HIV and determine whether HIV infection modified the effect of menopause on BMD changes. A 5-year population-based longitudinal study recruited women aged 40-60 years residing in Soweto and collected demographic and clinical data, including HIV status, anthropometry, and BMD, at baseline and at 5-year follow-up. All women were staged as pre-, peri-, or postmenopausal at both time points. Multivariable linear regression assessed relationships and interactions between HIV infection, menopause, and change in BMD. At baseline, 450 women had mean age 49.5 (SD 5.7) years, 65 (14.4%) had HIV, and 140 (31.1%), 119 (26.4%), and 191 (42.4%) were pre-, peri-, and postmenopausal, respectively; 34/205 (13.6%) women ≥50 years had a total hip (TH) or lumbar spine (LS) T-score ≤ -2.5. At follow-up 38 (8.4%), 84 (18.7%), and 328 (72.9%) were pre-, peri-, and postmenopausal. Those with HIV at baseline lost more total body (TB) BMD (mean difference -0.013 [95% confidence interval -0.026, -0.001] g/cm2 , p = 0.040) and gained more weight 1.96 [0.32, 3.60] kg; p = 0.019 than HIV-uninfected women. After adjusting for age, baseline weight, weight change, and follow-up time, the transition from pre- to postmenopause was associated with greater TB BMD losses in women with HIV (-0.092 [-0.042, -0.142] g/cm2 ; p = 0.001) than without HIV (-0.038 [-0.016, -0.060] g/cm2 , p = 0.001; interaction p = 0.034). Similarly, in women who were postmenopausal at both time points, those with HIV lost more TB BMD (-0.070 [-0.031, -0.108], p = 0.001) than women without HIV (-0.036 [-0.015, -0.057], p = 0.001, interaction p = 0.049). Findings were consistent but weaker at the LS and TH. Menopause-related bone loss is greater in women with HIV, suggesting women with HIV may be at greater risk of osteoporotic fractures. HIV services should consider routine bone health assessment in midlife women as part of long-term HIV care delivery. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Development of Hypertension and Diabetes Mellitus, and Associated Factors, Among Adult HIV Patients in Ethiopia

Background

Medical improvements and increased access to treatment have turned HIV from a highly fatal disease into a treatable and controllable disease. With the improvement in lifespan, HIV patients face increasing morbidity and mortality from chronic comorbidities (hypertension and diabetes mellitus). There is, nevertheless, a paucity of information on the scale of HIV noncommunicable disease comorbidity and its associated factors. This study aimed to investigate the incidence and predictors of chronic comorbidity in HIV patients in a resource-limited setting.

Methods

A prospective cohort study was conducted from 2019 to 2021. We included 520 HIV patients at baseline. Patients without hypertension or diabetes were followed for two years to determine the incidence of developing comorbidities. Nine trained nurses used a pre-tested structured questionnaire to collect data during routine care consultations in three hospitals in southern Ethiopia. To find predictors of these chronic comorbidities, a multivariable logistic regression analysis was used.

Results

After two years, 54 out of 377 participants, or 14%, had chronic comorbidity, which is defined as having diabetes and/or hypertension. Hypertension (12%) and diabetes (4%), respectively, were observed. When compared to those who were not overweight, the risk of developing chronic comorbidity was three times higher in overweight people [AOR = 3.45, 95% CI: (1.04, 11.45), P = 0.045]. Older participants were about 6 times more likely than younger participants to have chronic comorbidity [AOR = 4.93, 95% CI: (1.56, 15.57), P = 0.007]. Those who did not engage in regular physical activity were twice as likely to develop chronic comorbidity [AOR = 2.16, 95% CI: (1.09, 4.29), P = 0.027].

Conclusion

The incidence of chronic comorbidity was high in the study population. Targeted screening for early signs of chronic comorbidity, nutritional counseling, and awareness creation in regular physical activity programs should be integrated into HIV care to prevent and control chronic comorbidity in resource-limited settings.

The challenge of dealing with non-AIDS comorbidities for people living with HIV: Perspectives and experiences of patients and healthcare providers

As the cohort of People Living with HIV (PLHIV) ages, so does the spectrum and burden of non-AIDS define HIV-associated conditions (NARC). PLHIV are likely to need different and increased healthcare services. It requires health systems to adapt to this disease trend and conform to a chronic care model, which respects the distinct needs of the ageing population. In this article, we explore the lived experiences of PLHIV and their healthcare providers in managing the challenges of dealing with NARC in Arba Minch, Southern Ethiopia. This study utilises interpretative substantive methods, encompassing qualitative interviews and Focus Group Discussions. The Normalisation Practice Theory (NPT) guided the semi-structured questions concerning routine screenings and current models of HIV care for ageing individuals. The main structural challenges in providing adequate geriatric care included: (i) the lack of awareness of the risk of NARCs; (ii) the absence of blended care; (iii) an HIV-centred approach exclusive of multidisciplinary care; and (iv) financial constraints. In an era with increasing NARCs, traditional HIV care models must adapt to the emerging challenges of a 'greying' and growing population.

Antiretroviral therapy and aging as resources for managing and resisting HIV-related stigma in rural South Africa

The widespread roll-out of antiretroviral therapy (ART) in Africa has contributed to a large population of adults aging with HIV. However, little is known about how HIV-related stigma interacts with aging in the ART era. This study uses in-depth interviews with middle-aged and older South Africans living with HIV to explore stigma-related experiences and response strategies. Participants describe a persistence of stigma which requires the deployment of a range of common and age-based stigma management and resistance strategies. We find that participants minimize their exposure to stigma through selective disclosure of their HIV status; neutralize HIV-related stigma through comparisons to chronic illnesses common among older adults, and deflect stigma through asserting an ART-adherent identity and othering younger non-adherent adults. Overall, our study highlights the roles of ART and aging as resources for managing and resisting HIV-related stigma.

Multimorbidity and its socio-economic associations in community-dwelling older adults in rural Tanzania; a cross-sectional study

Objectives

This paper aims to describe the prevalence and socio-economic associations with multimorbidity, by both self-report and clinical assessment/screening methods in community-dwelling older people living in rural Tanzania.

Methods

A randomised frailty-weighted sample of non-institutionalised adults aged ≥ 60 years underwent comprehensive geriatric assessment and in-depth assessment. The comprehensive geriatric assessment consisted of a history and focused clinical examination. The in-depth assessment included standardised questionnaires, screening tools and blood pressure measurement. The prevalence of multimorbidity was calculated for self-report and non-self-reported methods (clinician diagnosis, screening tools and direct measurement). Multimorbidity was defined as having two or more conditions. The socio-demographic associations with multimorbidity were investigated by multiple logistic regression.

Results

A sample of 235 adults participated in the study, selected from a screened sample of 1207. The median age was 74 years (range 60 to 110 inter-quartile range (IQR) 19) and 136 (57.8%) were women. Adjusting for frailty-weighting, the prevalence of self-reported multimorbidity was 26.1% (95% CI 16.7–35.4), and by clinical assessment/screening was 67.3% (95% CI 57.0–77.5). Adjusting for age, sex, education and frailty status, multimorbidity by self-report increased the odds of being financially dependent on others threefold (OR 3.3 [95% CI 1.4–7.8]), and of a household member reducing their paid employment nearly fourfold (OR 3.8. [95% CI 1.5–9.2]).

Conclusions

Multimorbidity is prevalent in this rural lower-income African setting and is associated with evidence of household financial strain. Multimorbidity prevalence is higher when not reliant on self-reported methods, revealing that many conditions are underdiagnosed and undertreated.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14340-0.

Progress towards the UNAIDS 90-90-90 targets among persons aged 50 and older living with HIV in 13 African countries

Introduction

Achieving optimal HIV outcomes, as measured by global 90‐90‐90 targets, that is awareness of HIV‐positive status, receipt of antiretroviral (ARV) therapy among aware and viral load (VL) suppression among those on ARVs, respectively, is critical. However, few data from sub‐Saharan Africa (SSA) are available on older people (50+) living with HIV (OPLWH). We examined 90‐90‐90 progress by age, 15–49 (as a comparison) and 50+ years, with further analyses among 50+ (55–59, 60–64, 65+ vs. 50–54), in 13 countries (Cameroon, Cote d'Ivoire, Eswatini, Ethiopia, Kenya, Lesotho, Malawi, Namibia, Rwanda, Tanzania, Uganda, Zambia and Zimbabwe).

Methods

Using data from nationally representative Population‐based HIV Impact Assessments, conducted between 2015and 2019, participants from randomly selected households provided demographic and clinical information and whole blood specimens for HIV serology, VL and ARV testing. Survey weighted outcomes were estimated for 90‐90‐90 targets. Country‐specific Poisson regression models examined 90‐90‐90 variation among OPLWH age strata.

Results

Analyses included 24,826 HIV‐positive individuals (15–49 years: 20,170; 50+ years: 4656). The first, second and third 90 outcomes were achieved in 1, 10 and 5 countries, respectively, by those aged 15–49, while OPLWH achieved outcomes in 3, 13 and 12 countries, respectively. Among those aged 15–49, women were more likely to achieve 90‐90‐90 targets than men; however, among OPLWH, men were more likely to achieve first and third 90 targets than women, with second 90 achievement being equivalent. Country‐specific 90‐90‐90 regression models among OPLWH demonstrated minimal variation by age stratum across 13 countries. Among OLPWH, no first 90 target differences were noted by age strata; three countries varied in the second 90 by older age strata but not in a consistent direction; one country showed higher achievement of the third 90 in an older age stratum.

Conclusions

While OPLWH in these 13 countries were slightly more likely than younger people to be aware of their HIV‐positive status (first 90), this target was not achieved in most countries. However, OPLWH achieved treatment (second 90) and VL suppression (third 90) targets in more countries than PLWH <50. Findings support expanded HIV testing, prevention and treatment services to meet ongoing OPLWH health needs in SSA.

Priorities for health and wellbeing for older people with and without HIV in Uganda: a qualitative methods study

Introduction

With improved HIV treatment availability in sub‐Saharan Africa, the population of older people with HIV (PWH) is growing. In this qualitative study, we intended to understand (1) the lived experiences of ageing people in rural Uganda, with and without HIV, (2) their fears and health priorities as they grow older.

Methods

We conducted 36 semi‐structured interviews with individuals with and without HIV in Mbarara, Uganda from October 2019 to February 2020. Interview guide topics included priorities in older age, physical functioning in daily activities, social functioning, HIV‐related stigma and the impact of multimorbidity on health and independence. Interviews were conducted in Runyankole, transcribed, translated and inductively coded thematically by two researchers with tests for inter‐coder reliability.

Results

The respondents were purposively sampled to be evenly divided by sex and HIV serostatus. The median age of respondents was 57 (49–73). Two‐thirds were married or cohabitating, 94% had biological children and 75% cited farming as their primary livelihood. Overall, PWH considered themselves as healthy or healthier than people without HIV (PWOH). PWH rarely considered their HIV status a barrier to a healthy life, but some reported a constant sense of anxiety as it relates to their long‐term health. Irrespective of HIV status, nearly all respondents noted concerns about memory loss, physical pain, reductions in energy and the effect of these changes on their ability to complete physical tasks like small‐scale farming, and activities of daily living important to the quality of life, such as participating in community groups. Increasing reliance on others for social, physical and financial support was also a common theme. The most prevalent health concern among participants involved the threat of non‐communicable diseases and perceptions that physical functioning may diminish.

Conclusions

In rural Uganda, we found that PWH consider themselves to be healthy and do not anticipate a different ageing experience from PWOH. Common priorities shared by both groups included the desire for physical and financial independence, health maintenance and social support for daily functioning and social needs. Entities supporting geriatric care in Uganda would benefit from attention to concerns about functional limitations and reported needs as people age with and without HIV.

How health systems can adapt to a population ageing with HIV and comorbid disease

As people age with HIV, their needs increase beyond solely managing HIV care. Ageing people with HIV, defined as people with HIV who are 50 years or older, face increased risk of both age-regulated comorbidities and ageing-related issues. Globally, health-care systems have struggled to meet these changing needs of ageing people with HIV. We argue that health systems need to rethink care strategies to meet the growing needs of this population and propose models of care that meet these needs using the WHO health system building blocks. We focus on care provision for ageing people with HIV in the three different funding mechanisms: President's Emergency Plan for AIDS Relief and Global Fund funded nations, the USA, and single-payer government health-care systems. Although our categorisation is necessarily incomplete, our efforts provide a valuable contribution to the debate on health systems strengthening as the need for integrated, people-centred, health services increase.

Adaptation of a social vulnerability index for measuring social frailty among East African women

BACKGROUND

The number of older women living with HIV in Africa is growing, and their health outcomes may be adversely impacted by social frailty, which reflects deficits in social resources that accumulate over the lifespan. Our objective was to adapt a Social Vulnerability Index (SVI) originally developed in Canada for use in a study of older women living with or without HIV infection in Mombasa, Kenya.

METHODS

We adapted the SVI using a five-step process: formative qualitative work, translation into Kiswahili, a Delphi procedure, exploration of potential SVI items in qualitative work, and a rating and ranking exercise. Four focus group discussions (FGD) were conducted (three with women living with HIV and one with HIV-negative women), and two expert panels were constituted for this process.

RESULTS

Themes that emerged in the qualitative work were physical impairment with aging, decreased family support, a turn to religion and social groups, lack of a financial safety net, mixed support from healthcare providers, and stigma as an added burden for women living with HIV. Based on the formative FGD, the expert panel expanded the original 19-item SVI to include 34 items. The exploratory FGD and rating and ranking exercise led to a final 16-item Kenyan version of the SVI (SVI-Kenya) with six domains: physical safety, support from family, group participation, instrumental support, emotional support, and financial security.

CONCLUSIONS

The SVI-Kenya is a holistic index to measure social frailty among older women in Kenya, incorporating questions in multiple domains. Further research is needed to validate this adapted instrument.

Exploring drivers and barriers to the utilization of community client-led ART delivery model in South-Western Uganda: patients' and health workers' experiences

BACKGROUND

In an effort to accommodate the growing number of HIV clients, improve retention in care and reduce health care burden, the differentiated service delivery (DSD) models were introduced in 2014. One such model, Community Client-Led ART Delivery (CCLAD) was rolled out in Uganda in 2017. The extent of utilization of this model has not been fully studied. The aim of the study was to explore the patients' and health workers' experiences on the utilization of CCLAD model at Bwizibwera Health Centre IV, south western Uganda.

METHODS

This was a descriptive study employing qualitative methods. The study had 68 purposively selected participants who participated in 10 focus group discussions with HIV clients enrolled in CCLAD; 10 in-depth interviews with HIV clients not enrolled in CCLAD and 6 in-depth interviews with the health workers. Key informant interviews were held with the 2 focal persons for DSD. The discussions and interviews were audio recorded, transcribed verbatim and then translated. Both deductive and inductive approaches were employed to analyse the data using in NVivo software.

RESULTS

Patients' and health workers' experiences in this study were categorized as drivers and barriers to the utilization of the CCLAD model. The main drivers for utilization of this model at different levels were: individual (reduced costs, living positively with HIV, improved patient self-management), community (peer support and contextual factors) and health system (reduced patient congestion at the health centre, caring health workers as well as CCLAD sensitization by health workers). However, significant barriers to the utilization of this community-based model were: individual (personal values and preferences, lack of commitment of CCLAD group members), community (stigma, gender bias) and health system (frequent drug stockouts, certain implementation challenges, fluctuating implementing partner priorities, shortage of trained health workers and insufficient health education by health workers).

CONCLUSION

Based on our findings the CCLAD model is meeting the objectives set out by Differentiated Service Delivery for HIV care and treatment. Notwithstanding the benefits, challenges remain which call on the Ministry of Health and other implementing partners to address these hindrances to facilitate the scalability, sustainability and the realisation of the full-range of benefits that the model presents.

Older Adults Vastly Overestimate Both HIV Acquisition Risk and HIV Prevalence in Rural South Africa

Perceptions of HIV acquisition risk and prevalence shape sexual behavior in sub-Saharan Africa (SSA). We used data from the Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa baseline survey. Data were collected through home-based interviews of 5059 people ≥ 40 years old. We elicited information on perceived risk of HIV acquisition and HIV prevalence among adults  ≥ 15 and ≥ 50 years old. We first describe these perceptions in key subgroups and then compared them to actual estimates for this cohort. We then evaluated the relationship between sociodemographic characteristics and accurate perceptions of prevalence in regression models. Finally, we explored differences in behavioral characteristics among those who overestimated risk compared to those who underestimated or accurately estimated risk. Compared to the actual HIV acquisition risk of < 1%, respondents vastly overestimated this risk: 35% (95% CI: 32-37) and 34% (95% CI: 32-36) for men and women, respectively. Respondents overestimated HIV prevalence at 53% (95% CI: 52-53) for those ≥ 15 years old and 48% (95% CI: 48-49) for those ≥ 50 years old. True values were less than half of these estimates. There were few significant associations between demographic characteristics and accuracy. Finally, high overestimators of HIV prevalence tested themselves less for HIV compared to mild overestimators and accurate reporters. More than 30 years into the HIV epidemic, older people in a community with hyperendemic HIV in SSA vastly overestimate both HIV acquisition risk and prevalence. These misperceptions may lead to fatalism and reduced motivation for prevention efforts, possibly explaining the continued high HIV incidence in this community.

The effect of eligibility for antiretroviral therapy on body mass index and blood pressure in KwaZulu-Natal, South Africa

We use a regression discontinuity design to estimate the causal effect of antiretroviral therapy (ART) eligibility according to national treatment guidelines of South Africa on two risk factors for cardiovascular disease, body mass index (BMI) and blood pressure. We combine survey data collected in 2010 in KwaZulu-Natal, South Africa, with clinical data on ART. We find that early ART eligibility significantly reduces systolic and diastolic blood pressure. We do not find any significant effects on BMI. The effect on blood pressure can be detected up to three years after becoming eligible for ART.

Setting priorities for ageing research in Africa: A systematic mapping review of 512 studies from sub-Saharan Africa

Background

In 2040, the older population's growth rate in sub-Saharan Africa (SSA) will be faster than those experienced by developed nations since 1950. In preparation for this growth, the National Institute on Aging commissioned the National Academies' Committee on Population to organize a workshop on advancing aging research in Africa. This meeting provided a platform for discussing some areas requiring improvement in aging research in SSA regions. We believed that conducting a systematic review of peer-reviewed articles to set priorities for aging research in SSA is warranted. Therefore, this article is the first in a Four-Part series that summaries the types and trends of peer-reviewed studies in SSA.

Methods

This systematic mapping review followed the Search-Appraisal-Synthesis-Analysis Framework. We systematically searched multiple databases from inception till February 2021 and included peer-reviewed articles conducted with/for older adults residing in SSA. Conventional content analysis was employed to categorize studies into subject-related areas.

Results

We included 512 studies (quantitative = 426, qualitative = 71 and mixed-method = 15). Studies were conducted in 32 countries. Quantitative studies included were observational studies: cross-sectional (n = 250, 59%), longitudinal (n = 126, 30%), and case-control (n = 12, 3%); and experimental studies: pre-post design (n = 4, 1%), randomized control trial (RCT, n = 12, 3%); and not reported (n = 21, 5%). Fifteen qualitative studies did not state their study design; where stated, study design ranged from descriptive (n = 14, 20%), ethnography (n = 12, 17%), grounded theory (n = 7, 10%), narrative (n = 5, 7%), phenomenology (n = 10, 14%), interpretative exploratory (n = 4, 6%), case studies (n = 4, 6%). Of the 15 mixed-method studies, seven did not state their mixed-method design. Where stated, design includes concurrent (n = 1), convergent (n = 1), cross-sectional (n = 3), informative (n = 1), sequential exploratory (n = 1) and retrospective (n = 2). Studies were classified into 30 (for quantitative studies) and seven (for qualitative and mixed-method) subject-related areas. HIV/AIDs-related and non-communicable diseases-related studies were the most predominant subject-related areas. No studies explored the transdisciplinary co-production of interventions.

Conclusions

There are glaring gaps in ageing research in SSA, especially mixed-methods and RCTs. A large number of studies focused on HIV/AIDs and non-communicable disease-related studies. National and international funding agencies should set up priority funding competitions for transdisciplinary collaborations in ageing research.

Setting priorities for ageing research in Africa: A systematic mapping review of 512 studies from sub-Saharan Africa

BACKGROUND

In 2040, the older population's growth rate in sub-Saharan Africa (SSA) will be faster than those experienced by developed nations since 1950. In preparation for this growth, the National Institute on Aging commissioned the National Academies' Committee on Population to organize a workshop on advancing aging research in Africa. This meeting provided a platform for discussing some areas requiring improvement in aging research in SSA regions. We believed that conducting a systematic review of peer-reviewed articles to set priorities for aging research in SSA is warranted. Therefore, this article is the first in a Four-Part series that summaries the types and trends of peer-reviewed studies in SSA.

METHODS

This systematic mapping review followed the Search-Appraisal-Synthesis-Analysis Framework. We systematically searched multiple databases from inception till February 2021 and included peer-reviewed articles conducted with/for older adults residing in SSA. Conventional content analysis was employed to categorize studies into subject-related areas.

RESULTS

We included 512 studies (quantitative = 426, qualitative = 71 and mixed-method = 15). Studies were conducted in 32 countries. Quantitative studies included were observational studies: cross-sectional (n = 250, 59%), longitudinal (n = 126, 30%), and case-control (n = 12, 3%); and experimental studies: pre-post design (n = 4, 1%), randomized control trial (RCT, n = 12, 3%); and not reported (n = 21, 5%). Fifteen qualitative studies did not state their study design; where stated, study design ranged from descriptive (n = 14, 20%), ethnography (n = 12, 17%), grounded theory (n = 7, 10%), narrative (n = 5, 7%), phenomenology (n = 10, 14%), interpretative exploratory (n = 4, 6%), case studies (n = 4, 6%). Of the 15 mixed-method studies, seven did not state their mixed-method design. Where stated, design includes concurrent (n = 1), convergent (n = 1), cross-sectional (n = 3), informative (n = 1), sequential exploratory (n = 1) and retrospective (n = 2). Studies were classified into 30 (for quantitative studies) and seven (for qualitative and mixed-method) subject-related areas. HIV/AIDs-related and non-communicable diseases-related studies were the most predominant subject-related areas. No studies explored the transdisciplinary co-production of interventions.

CONCLUSIONS

There are glaring gaps in ageing research in SSA, especially mixed-methods and RCTs. A large number of studies focused on HIV/AIDs and non-communicable disease-related studies. National and international funding agencies should set up priority funding competitions for transdisciplinary collaborations in ageing research.

From "Secret" to "Sensitive Issue": Shifting Ideas About HIV Disclosure Among Middle-Aged and Older Rural South Africans in the Era of Antiretroviral Treatment

OBJECTIVE

As HIV shifts from "death sentence" to "chronic condition," disclosure of HIV status to intimate partners and family is a significant component of both prevention and treatment adherence. While disclosure is closely considered in many studies, few examine middle-aged and older persons' (age 40+) perspectives or practices. We trace older rural South Africans' views on HIV disclosure to their partners and family members in a high prevalence community over a period of extensive antiretroviral treatment (ART) rollout.

METHODS

Community focus group discussions (FGD) conducted in 2013 and 2018 show shifts in older persons' thinking about HIV disclosure.

FINDINGS

Our FGD participants saw fewer negative consequences of disclosure in 2018 than in 2013, and highlighted positive outcomes including building trust (partners) as well as greater support for medication collection and adherence (family).

DISCUSSION

Particularly as the epidemic ages in South Africa and globally, tracing changes in older persons' views on disclosure is an important step in developing messaging that could enhance treatment as prevention and ART adherence.

Current co-morbidities burden in patients living with HIV in low- and middle-income countries

PURPOSE OF REVIEW

The present review aims to decipher common co-morbidities faced by people living with HIV in low- to middle-income countries, and in particular the sub-Saharan region, which hosts the majority of the HIV burden worldwide.

RECENT FINDINGS

Well-controlled chronic HIV disease is strongly associated with an increased risk of developing cardiovascular disease. This is partly due to the natural aging process, however recent studies show that using antiretroviral therapy as well as the HIV disease itself may be predisposing factors to the development of cardiovascular diseases, creating a new burden for healthcare facilities in the region. Furthermore, newly completed studies assessing inflammation marker albuminuria and age-related syndrome frailty have been found in a higher prevalence than in non-HIV people, with increased morbidity and mortality.

SUMMARY

As antiretroviral medication continues to be well supplied in the region and well tolerated by patients living with HIV, this group is now reckoning with cardiovascular ailments faced by all ageing population therefore there is a need for cardiovascular care systems to be better integrated within the existing, well-performing HIV care cascade to address this burden.

Cost-effectiveness analysis of integrating screening and treatment of selected non-communicable diseases into HIV/AIDS treatment in Uganda

INTRODUCTION

Despite growing enthusiasm for integrating treatment of non-communicable diseases (NCDs) into human immunodeficiency virus (HIV) care and treatment services in sub-Saharan Africa, there is little evidence on the potential health and financial consequences of such integration. We aim to study the cost-effectiveness of basic NCD-HIV integration in a Ugandan setting.

METHODS

We developed an epidemiologic-cost model to analyze, from the provider perspective, the cost-effectiveness of integrating hypertension, diabetes mellitus (DM) and high cholesterol screening and treatment for people living with HIV (PLWH) receiving antiretroviral therapy (ART) in Uganda. We utilized cardiovascular disease (CVD) risk estimations drawing from the previously established Globorisk model and systematic reviews; HIV and NCD risk factor prevalence from the World Health Organization's STEPwise approach to Surveillance survey and global databases; and cost data from national drug price lists, expert consultation and the literature. Averted CVD cases and corresponding disability-adjusted life years were estimated over 10 subsequent years along with incremental cost-effectiveness of the integration.

RESULTS

Integrating services for hypertension, DM, and high cholesterol among ART patients in Uganda was associated with a mean decrease of the 10-year risk of a CVD event: from 8.2 to 6.6% in older PLWH women (absolute risk reduction of 1.6%), and from 10.7 to 9.5% in older PLWH men (absolute risk reduction of 1.2%), respectively. Integration would yield estimated net costs between $1,400 and $3,250 per disability-adjusted life year averted among older ART patients.

CONCLUSIONS

Providing services for hypertension, DM and high cholesterol for Ugandan ART patients would reduce the overall CVD risk among these patients; it would amount to about 2.4% of national HIV/AIDS expenditure, and would present a cost-effectiveness comparable to other standalone interventions to address NCDs in low- and middle-income country settings.

Brief Report: HIV Incidence Among Older Adults in a Rural South African Setting: 2010-2015

In South Africa, evidence shows high HIV prevalence in older populations, with sexual behavior consistent with high HIV acquisition and transmission risk. However, there is a dearth of evidence on older people's HIV incidence.

HIV and Aging: Double Stigma

Purpose of Review

HIV and ageism continue to be key public health challenges in the USA and globally. Older people living with HIV may experience intersectional stigma resulting from HIV and ageism. The current review summarizes the scientific literature and focuses on social isolation and lack of social support as key factors in experiencing HIV-related and aging-related stigma.

Recent Findings

Social isolation and social support are key social determinants of health, which may have a bidirectional relationship with HIV-related stigma and ageism. Stigmatization may also result in health care providers not paying enough attention to the mental health and sexual health needs of older adults.

Summary

Current research suggests that the intersection of HIV-related stigma and ageism is a complex issue. Future research should focus on the design and feasibility of implementing stigma reduction interventions addressing HIV-related stigma and ageism.

Aging of HIV epidemic in India: Insights from HIV estimation modeling under the national aids control programme

People living with HIV are gradually getting older as a result of better survival with increased uptake of antiretroviral treatment in India. We aimed to quantify the aging HIV-infected population in India by undertaking a mathematical model analysis of 2017 rounds of HIV burden estimations under the National AIDS Control Programme. Our analysis projects that the mean age of HIV-infected people will increase from 38.4 years in 2005 to 45.5 years in 2025 with the proportion of HIV-infected people aged 50 years or older increasing from 19% in 2005 to 37% in 2025. This aging HIV epidemic is anticipated to lead to more non-AIDS morbidities, increased treatment complexity, and an inevitable need for multidisciplinary health-care services to ensure continued high-quality survival.

Cerebral alterations in West African HIV and non-HIV adults aged ≥50: An MRI study

Objectives:

To cross-sectionally describe brain alterations in PLHIV aged above 50 years old, receiving antiretroviral treatment (ART) and living in Senegal compared to HIV-negative subjects.

Methods:

Twenty PLHIV and 26 HIV-negative subjects with comparable socio-demographic and clinical characteristics underwent an MRI exam (3D-T1 and FLAIR sequences). Global atrophy and White Matter Hyperintensities (WMH) were evaluated. After assessing the feasibility and acceptability of MRI scans in this population, we described atrophy and WHM prevalence and associated factors using logistic regressions.

Results:

Overall, 43.5% of the study sample were aged ≥60 years, 58.7% were women, and 28.3% had hypertension. The overall prevalence of atrophy and WMH was 19.6% [95% CI: 8.1–31.1] and 30.4% [95% CI: 17.1–43.7]. HIV status had no significant effect on atrophy or WMH. Unemployment and hypertension were significantly associated with atrophy, whereas women were less likely to present atrophy. Aged ≥60 years was the only factor associated with WMH.

Conclusions:

A high prevalence of atrophy and WMH was observed in West African adults aged over 50 years without a clear HIV impact. As brain MRI studies are critical to better understand cognitive and emotional outcomes, we encourage those studies in older PLHIV in West Africa.

Cohort profile: the Nigerian HIV geriatric cohort study

BACKGROUND

The Nigerian HIV Geriatric Cohort (NHGC) is a longitudinal cohort setup to learn how elderly people living with HIV (EPLHIV) in Nigeria fare, despite not being prioritized by the national treatment program, and to deepen knowledge for their differentiated care and achieve better outcomes. In this paper, we describe data collected on sociodemographic and clinical data from EPLHIV from the inception of Nigeria's national HIV program to 2018.

METHODS

Patient-level data spanning the period 2004 to 2018, obtained from comprehensive HIV treatment hospitals, that are supported by four major PEPFAR-implementing partners in Nigeria were used. These 4 entities collaborated as member organizations of the Nigeria Implementation Science Alliance. We defined elderly as those aged 50 years and above. From deidentified treatment records, demographic and clinical data of EPLHIV ≥50-year-old at ART initiation during the review period was extracted, merged into a single REDcap® database, and described using STATA 13.

RESULTS

A total of 101,652 EPLHIV were analysed. Women accounted for 53,608 (53%), 51,037 (71%) of EPLHIV identified as married and 33,446 (51%) unemployed. Median age was 57.1 years (IQR 52-60 years) with a median duration on ART treatment of 4.1 years (IQR 1.7-7.1 years). ART profile showed that 97,586 (96%) were on 1st-line and 66,125 (65%) were on TDF-based regimens. Median body mass index (BMI) was 22.2 kg/m² (IQR 19.5-25.4 kg/m²) with 43,012 (55%), 15,081 (19%) and 6803 (9%) showing normal (BMI 18.5 - < 25 kg/m²), overweight (BMI 25 - < 30 kg/m²) and obese (BMI ≥30 kg/m²) ranges respectively. Prevalence of hypertension (systolic-BP > 140 mmHg or diastolic-BP > 90 mmHg) was 16,201 (21%). EPLHIV median CD4 count was 381 cells/μL (IQR 212-577 cells/μL) and 26,687 (82%) had a viral load result showing < 1000copies/ml within one year of their last visit. As for outcomes at their last visit, 62,821 (62%) were on active-in-treatment, 28,463 (28%) were lost-to-follow-up, 6912 (7%) died and 2456 (3%) had stopped or transferred out. Poor population death records and aversion to autopsies makes it almost impossible to estimate AIDS-related deaths.

CONCLUSIONS

This cohort describes the clinical and non-clinical profile of EPLHIV in Nigeria. We are following up the cohort to design and implement intervention programs, develop prognostic models to achieve better care outcomes for EPLHIV. This cohort would provide vital information for stakeholders in HIV prevention, care and treatment to understand the characteristics of EPLHIV.

HIV serostatus, inflammatory biomarkers and the frailty phenotype among older people in rural KwaZulu-Natal, South Africa

Objective: We compared the prevalence of frailty by HIV serostatus and related biomarkers to the modified frailty phenotype among older individuals in a rural population in South Africa. Methods: Questionnaire data were from a cohort of people living with HIV (PWH) on antiretroviral therapy (ART) and HIV-uninfected people aged 50 years and older sampled from the Africa Health Research Institute Demographic Health and Surveillance area in northern KwaZulu-Natal. The prevalence of frailty was compared using five categories: (1) physical activity; (2) mobility; (3) fatigue; (4) gait speed; and (5) grip strength, and assessed for demographic, clinical, and inflammatory correlates of frailty. Results: Among 614 individuals in the study, 384 (62.5%) were women. The median age at study enrolment was 64 years [Interquartile range (IQR) (58.6-72.0)]. 292 (47.6%) were PWH. 499 (81%) were classified as either pre-frail or frail. 43 (7%) were frail and HIV positive, 185 (30%) were pre-frail and HIV positive, 57 were frail and HIV negative and 214 (35%) were pre-frail and HIV negative. Frailty was similar for HIV negative and PWH (17.7% vs 14.7%, p = 0.72). Women were more likely to be frail (18.3% vs 13.04%, p = 0.16). The prevalence of frailty increased with age for both HIV groups. In the multivariable analysis, the odds of being frail were higher in those aged 70 years and above than those aged between 50 and 59 years (p < 0.001). Females were less likely to be pre-frail than males (p < 0.001). There was no association between any of the inflammatory biomarkers and frailty and pre-frailty. Conclusion: In this population, the prevalence of frailty is similar for PWH and people without HIV, but higher for women than men. These data suggest that the odds of developing frailty is similar for PWH over the age of 50 years, who survive into older age, as for people without HIV.

Effects of HIV and non-communicable disease comorbidity on healthcare costs and health experiences in people living with HIV in Zimbabwe

BACKGROUND

The effects of HIV and non-communicable disease (NCD) comorbidities on healthcare costs and health experiences have been documented in most high-income countries. However, little similar data are available for Zimbabwe and most countries in sub-Saharan Africa. Untreated or under-treated NCDs can potentially negate the gains achieved from the control of HIV.

OBJECTIVES

The study sought to determine the effects of HIV-NCD comorbidity on healthcare costs, health experiences and treatment options for people living with HIV (PLWH) in Zimbabwe.

METHODS

A repeated-measures, quantitative study was conducted at six antiretroviral therapy (ART) sites in the Gweru District of Zimbabwe. Simple random sampling was used to enrol 100 PLWH concurrently diagnosed with hypertension and/or diabetes mellitus (cases). Cases were matched by age, sex and viral load to an equal number of PLWH without hypertension and/or diabetes mellitus (controls). Quantitative data were collected using an interviewer-administered questionnaire at monthly intervals for 6 months. The questionnaire survey sought to compare healthcare costs, health-related experiences and treatment options between cases and controls. Data were analysed using Stata Version 13.1®. A logistic model was used to examine other factors such as demographic, clinical and behavioural data that were assumed to be unchanged over the study period. A random-effects model, including costs and other covariates, was used to compare groups in the final analysis.

RESULTS

Non-communicable disease status was associated with the length of time on ART. Cases spent significantly more on transport (p = 0.0001) and medication (adjusted odds ratio [AOR] = 4.4, 95% confidence interval [CI]: 3.2-7.3); spent more days without doing usual daily activities because of sickness (AOR = 4.2, 95% CI: 3.3-7.6) and were more likely to use alternative medication (AOR = 3.4, 95% CI: 2.3-4.6) when compared with controls. Unemployment, female gender, age of 60 years and above, and living in rural areas were associated with failure to purchase prescribed medication.

CONCLUSIONS

HIV-NCD comorbidity causes an additional burden to PLWH because of increased transport costs, NCD prescribed medication expenses and more productive days lost due to illness. The success of HIV programmes does not only rely on improving access to the diagnosis and treatment of HIV. Addressing the complications of HIV-related NCDs, and the long-term costs of ART and its occasional potential for harm will be essential if health outcomes in Zimbabweans living with HIV are to be optimised.

Comorbidity of HIV, hypertension, and diabetes and associated factors among people receiving antiretroviral therapy in Bahir Dar city, Ethiopia

Background:

People living with human immunodeficiency virus (HIV) are facing an increased burden of noncommunicable diseases (NCDs) comorbidity. There is, however, paucity of information on the magnitude of HIV-NCDs comorbidity, its associated factors, and how the health system is responding to the double burden in Ethiopia.

Objective:

To determine the magnitude of comorbidity between HIV and hypertension or diabetes and associated factors among HIV-positive adults receiving antiretroviral therapy (ART) in Bahir Dar city, Ethiopia.

Methods:

A facility-based cross-sectional study was conducted among 560 randomly selected HIV-positive adults taking ART. Data were collected using a structured questionnaire and analyzed using SPSS version 23. Descriptive statistics were used to describe the data. A logistic regression model was fit to identify associated factors with comorbidity of HIV and NCDs.

Results:

The magnitude of comorbidity was 19.6% (95% confidence interval (CI): 16.0–23.0). Being older (55 and above years) adjusted odds ratio (AOR: 8.5; 95% CI: 3.2–15.1), taking second-line ART regimen containing tenofovir (AOR: 2.7; 95% CI: 1.3–5.6), and increased body mass index (BMI) ≥25 (AOR: 2.7; 95% CI: 1.2–6.5) were the factors associated with comorbidity. Participants reported that they were not managed in an integrated and coordinated manner.

Conclusions:

The magnitude of comorbidity among adults was high in the study area. Being older, second-line ART regimen and high BMI ≥25 increased the odds of having NCDs among HIV-positive adults. Targeted screening for the incidences of NCDs, addressing modifiable risk factors, and providing integrated care would help to improve the quality of life comorbid patients.

Assessing the feasibility of a life history calendar to measure HIV risk and health in older South Africans

Life history calendars capture patterns of behavior over time, uncovering transitions and trajectories. Despite the growing numbers of older persons living with HIV in southern Africa, little is known about how HIV testing and risk unfold in this population. Operationalizing a life course approach with the use of an innovative Testing and Risk History Calendar [TRHC], we collected pilot data on older South Africans' risk and HIV testing. We found older persons were able to provide (1) reference points to facilitate recall over a 10-year period, (2) specifics about HIV tests during that decade, and (3) details that contextualize the testing data, such as living arrangements, relationships, and health status. Interviewer debriefing sessions after each interview captured information on context and links across domains. On a larger scale, the TRHC has potential to reveal pathways between sexual behavior, HIV testing and risk perception, and health at older ages.

Implementing routine physical function screening among elderly HIV-positive patients in Uganda

We conducted a cross-sectional study to describe routine physical function assessment for HIV-infected adults aged ≥60 years attending a large urban HIV clinic in Kampala, Uganda. Assessed demographic and clinical factors associated with low physical function in the population, generalized linear regression model was used to estimate factors associated with low physical function. Of the 93 elderly patients that underwent the Short Physical Performance Battery (SPPB) assessment, 43/93 (44.1%) scored 1-8 points at the SPPB evaluation and were categorized as low function, 45/93 (48.4%) scored 9-11 points and were categorized as moderate function and 7/93 (7.5%) scored 12 points and were categorized as high (normal) function. Women (adjusted risk ratio (ARR) 2.57; 95% confidence interval (CI): 1.54-4.29, p = 0.000) had increased risk of low physical function compared to men. A one-year increase in age (ARR = 1.09; CI: 1.03-1.15, p = 0.004) and being overweight (BMI > 25.0, ARR = 1.96; CI: 1.89-3.24, p = 0.008) also carried an increased risk of low physical function status. A higher number 13/41(32%) of falls was recorded in female than among male 3/53(5.8%) patients (p = 0.001). The SPPB assessment is a starting point for clinicians to comprehensively evaluate and consider the management of physical function limitation among older HIV-positive patients.

Pain-Specific Resilience in People Living With HIV and Chronic Pain: Beneficial Associations With Coping Strategies and Catastrophizing

Objective

Chronic pain is increasingly recognized as a common and disabling problem for people living with HIV (PLWH). In a recent systematic review of psychosocial factors associated with chronic pain in PLWH, it was reported that very few studies to date have examined protective psychological factors that might help mitigate chronic pain for PLWH. The current study examined pain-specific resilience in relation to clinical and experimental pain, as well as pain coping in PLWH and chronic pain. Pain-specific resilience specifically refers to the ability to maintain relatively stable, healthy levels of psychological and physical functioning in the face of ongoing and persistent pain.

Methods

A total of 85 PLWH (mean CD4 = 643; 13% detectable viral load ≥200; 99% on antiretroviral therapy) who met criteria for chronic pain (>3 consecutive month’s duration) were enrolled. Medical records were reviewed to confirm clinical data. All participants provided sociodemographic information prior to completing the following validated measures: Pain Resilience Scale (PRS), Coping Strategies Questionnaire-Revised (CSQ-R), Center for Epidemiologic Studies – Depression Scale (CES-D), and the Brief Pain Inventory – Short Form (BPI-SF). They then completed a quantitative sensory testing battery designed to assess tolerance for painful heat and cold stimuli.

Results

In adjusted multiple regression models controlling for covariates, greater pain-specific resilience was significantly associated with less pain interference (p = 0.022) on the BPI-SF, less pain catastrophizing (p = 0.002), greater use of distraction (p = 0.027) and coping self-statements (p = 0.039) on the CSQ-R, as well as significantly greater heat pain tolerance (p = 0.009). Finally, results of a parallel multiple mediation model demonstrated that the effect of pain-specific resilience on heat pain tolerance was indirectly transmitted through less pain catastrophizing (95% confidence interval:0.0042 to 0.0354), but not use of distraction (95% confidence interval: −0.0140 to 0.0137) or coping self-statements (95% confidence interval: −0.0075 to 0.0255).

Conclusion

The findings suggest that pain-specific resilience may promote adaptation and positive coping in PLWH and chronic pain.

Prevalence and health effects of communicable and non-communicable disease comorbidity in rural KwaZulu-Natal, South Africa

OBJECTIVES

To describe changes in prevalence of hypertension, diabetes, HIV and tuberculosis, and prevalence of comorbidity, and to investigate associations between each condition, and combinations of conditions, with self-reported general health and hospital admission.

METHODS

This study used data from a longitudinal population-based HIV and health surveillance cohort, conducted by the Africa Health Research Institute in Umkhanyakude district of rural KwaZulu-Natal, South Africa.

RESULTS

Prevalence of hypertension, HIV and diabetes increased from 2009 to 2015, and prevalence of tuberculosis decreased. 81% of the 47 334 participants were female; hypertension and diabetes were the commonest conditions in people over age 50, whereas HIV was most common in those younger than 50 years. Comorbidity of communicable and non-communicable conditions was commonest in 40- to 60-year-olds. The adjusted odd ratios (OR) for better self-reported general health with multimorbidity were 0.53 (95% CI 0.51-0.56), 0.29 (95% CI 0.27-0.29), 0.25 (95% CI 0.21-0.37) and 0.21 (95% CI 0.12-0.37) for one, two, three and four conditions, respectively, vs. no conditions. Tuberculosis was most strongly and inversely associated with better general health (OR 0.34 (0.31-0.37) and most strongly associated with hospital admission (OR 3.26 (2.32-2.99)).

CONCLUSION

The high prevalence of communicable and non-communicable conditions in this rural South African population is giving rise to a burden of multimorbidity, as increased access to antiretroviral treatment has reduced mortality in people with HIV. Healthcare systems must adapt by working towards integrated primary care for HIV/AIDS and non-communicable diseases.

High Cancer Burden Among Antiretroviral Therapy Users in Malawi: A Record Linkage Study of Observational Human Immunodeficiency Virus Cohorts and Cancer Registry Data

BACKGROUND

With antiretroviral therapy (ART), AIDS-defining cancer incidence has declined and non-AIDS-defining cancers (NADCs) are now more frequent among human immunodeficiency virus (HIV)-infected populations in high-income countries. In sub-Saharan Africa, limited epidemiological data describe cancer burden among ART users.

METHODS

We used probabilistic algorithms to link cases from the population-based cancer registry with electronic medical records supporting ART delivery in Malawi's 2 largest HIV cohorts from 2000-2010. Age-adjusted cancer incidence rates (IRs) and 95% confidence intervals were estimated by cancer site, early vs late incidence periods (4-24 and >24 months after ART start), and World Health Organization (WHO) stage among naive ART initiators enrolled for at least 90 days.

RESULTS

We identified 4346 cancers among 28 576 persons. Most people initiated ART at advanced WHO stages 3 or 4 (60%); 12% of patients had prevalent malignancies at ART initiation, which were predominantly AIDS-defining eligibility criteria for initiating ART. Kaposi sarcoma (KS) had the highest IR (634.7 per 100 000 person-years) followed by cervical cancer (36.6). KS incidence was highest during the early period 4-24 months after ART initiation. NADCs accounted for 6% of new cancers.

CONCLUSIONS

Under historical ART guidelines, NADCs were observed at low rates and were eclipsed by high KS and cervical cancer burden. Cancer burden among Malawian ART users does not yet mirror that in high-income countries. Integrated cancer screening and management in HIV clinics, especially for KS and cervical cancer, remain important priorities in the current Malawi context.

HIV, antiretroviral therapy and non-communicable diseases in sub-Saharan Africa: empirical evidence from 44 countries over the period 2000 to 2016

INTRODUCTION

The HIV-infected population is growing due to the increased accessibility of antiretroviral therapy (ART) that extends the lifespan of people living with HIV (PLHIV). We aimed to assess whether national HIV prevalence and ART use are associated with an increased prevalence of cardiovascular risk factors.

METHODS

Using country-level data, we analysed the effect of HIV prevalence and use of ART on cardiovascular risk factors in 44 countries in sub-Saharan Africa between 2000 and 2016. We used fixed-effects estimation to quantify the effect of HIV and ART on the prevalence of diabetes, mean body mass index, the prevalence of overweight, obesity and hypertension, and mean systolic blood pressure. The models were adjusted for calendar time, the age structure of the population, income and education.

RESULTS

Diabetes prevalence among PLHIV was 5.8 percentage points higher (95% confidence interval (CI) 1.8 pp to 9.8 pp) compared to individuals without HIV. People receiving ART had a 4.6 percentage point higher prevalence (95% CI 2.6 pp to 6.6 pp). The prevalence of obesity was increased by 14.7 percentage points (95% CI 2.5 pp to 26.9 pp) for PLHIV. Receiving ART was associated with an increased obesity prevalence by 14.0 percentage points (95% CI 4.8 pp to 23.2 pp), whereas it had no significant association with the prevalence of overweight. The population aged 40 to 59 had a significantly higher prevalence of diabetes, overweight and obesity. HIV prevalence and ART use had no significant association with the prevalence of hypertension.

CONCLUSIONS

An ageing HIV-infected population on ART is associated with a significant increase in the prevalence of diabetes and obesity in sub-Saharan Africa. The increasing prevalence of these cardiovascular risk factors emphasizes the need for comprehensive healthcare programmes that screen and treat both HIV and non-communicable diseases to decrease the associated morbidity and mortality rates.

HIV treatment cascade for older adults in rural South Africa

OBJECTIVES

The HIV treatment cascade is a powerful framework for understanding progress from initial diagnosis to successful treatment. Data sources for cascades vary and often are based on clinical cohorts, population cohorts linked to clinics, or self-reported information. We use both biomarkers and self-reported data from a large population-based cohort of older South Africans to establish the first HIV cascade for this growing segment of the HIV-positive population and compare results using the different data sources.

METHODS

Data came from the Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa (HAALSI) 2015 baseline survey of 5059 adults aged 40+ years. Dried blood spots (DBS) were screened for HIV, antiretroviral drugs and viral load. In-home surveys asked about HIV testing, diagnosis and antiretroviral therapy (ART) use. We calculated proportions and CIs for each stage of the cascade, conditional on attainment of the previous stage, using (1) biomarkers, (2) self-report and (3) both biomarkers and self-report, and compared with UNAIDS 90-90-90 targets.

RESULTS

4560 participants had DBS results, among whom 1048 (23%) screened HIV-positive and comprised the denominator for each cascade. The biomarker cascade showed 63% (95% CI 60 to 66) on ART and 72% (95% CI 69 to 76) of those on ART with viral suppression. Self-reports underestimated testing, diagnosis and ART, with only 47% (95% CI 44 to 50) of HIV-positive individuals reporting ART use. The combined cascade indicated high HIV testing (89% (95% CI 87 to 91)), but lower knowledge of HIV-positive status (71% (95% CI 68 to 74)).

CONCLUSIONS

Older South Africans need repeated HIV testing and sustained ART to reach 90-90-90 targets. HIV cascades relying on self-reports are likely to underestimate true cascade attainment, and biomarkers provide substantial improvements to cascade estimates.

HIV prevalence and related behaviours of older people in Botswana - secondary analysis of the Botswana AIDS Impact Survey (BAIS) IV

The focus of HIV interventions in Botswana, a country with the second highest prevalence of HIV in the world, remains targeted at those aged 15-49 years despite a growing cohort of older people living with the disease - driven largely by the successful roll-out of antiretroviral therapy (ART). Primarily utilising the Botswana AIDS Impact Survey IV, we set out to examine HIV related characteristics and behaviours of this often ignored older cohort (50-64 years) relative to younger (25-49 years) adults. Analysis revealed that more than 80% of older people living with HIV were on ART. HIV prevalence among this older cohort was 24.6% in 2013 compared to 35.1% among the younger cohort, p < 0.0001. Prevalence in older adults was higher among older males (27.8%) than females (21.9%), p = 0.02. Furthermore, 58.9% of older adults acknowledged being sexually active, with 59.0% of these admitting to inconsistent condom use during sexual intercourse. In addition to this low condom usage, older men (6.0%) were significantly more likely to be unaware of their HIV-positive status than older women (3.0%), p = 0.002. While HIV prevalence showed a dramatic increase among older men over time (17.2% in 2004, to 23.4% in 2008, to 27.8% in 2013), the trend was flatter among older women (16.3% in 2004, to 22.4% in 2008, to 21.9% in 2013). These trends are likely attributable to a large increase in ART coverage and uptake. Going forward, more targeted interventions acknowledging the ageing epidemic are important to consider.

Comparison of Antiretroviral Therapy Adherence Among HIV-Infected Older Adults with Younger Adults in Africa: Systematic Review and Meta-analysis

As access to antiretroviral treatment in low- and middle-income countries improves, the number of older adults (aged ≥ 50 years) living with HIV is increasing. This study compares the adherence to antiretroviral treatment among older adults to that of younger adults living in Africa. We searched PubMed, Medline, Cochrane CENTRAL, CINAHL, Google Scholar and EMBASE for keywords (HIV, ART, compliance, adherence, age, Africa) on publications from 1st Jan 2000 to 1st March 2016. Eligible studies were pooled for meta-analysis using a random-effects model, with the odds ratio as the primary outcome. Twenty studies were included, among them were five randomised trials and five cohort studies. Overall, we pooled data for 148,819 individuals in two groups (older and younger adults) and found no significant difference in adherence between them [odds ratio (OR) 1.01; 95% CI 0.94–1.09]. Subgroup analyses of studies using medication possession ratio and clinician counts to measure adherence revealed higher proportions of older adults were adherent to medication regimens compared with younger adults (OR 1.06; 95% CI 1.02–1.11). Antiretroviral treatment adherence levels among older and younger adults in Africa are comparable. Further research is required to identify specific barriers to adherence in the aging HIV affected population in Africa which will help in development of interventions to improve their clinical outcomes and quality of life.

"For us here, we remind ourselves": strategies and barriers to ART access and adherence among older Ugandans

BACKGROUND

Very little is known about the barriers and facilitators to antiretroviral therapy (ART) access and adherence among older Africans. Most studies on ART have focused on individuals who are 15-49 years of age.

METHODS

We used in-depth interviews with 40 persons living with HIV, aged 50 to 96 years, who had either initiated ART (n = 26) or were waiting to initiate ART (n = 14), to explore barriers and facilitators to ART access and adherence in rural Uganda.

RESULTS

Guided by the Andersen Behavior Model, thematic content analysis highlighted 21 primary factors related to environment, patient and health behavior. Nine of the factors were common to both access and adherence, the remaining 12 were evenly split between access and adherence. Transportation costs, food insecurity, and healthcare workers' knowledge, attitudes and behaviors were key barriers.

CONCLUSIONS

These barriers were similar to those outlined for younger populations in other studies, but were compounded by age. Despite barriers, either due to the exceptional nature of HIV care or overreporting, both ART access and self-reported adherence were better than expected. Older persons living with HIV highlighted health care needs for non-HIV-related illnesses, suggesting while HIV care is adequate, care for the ailments of "old age" is lagging.

Global and regional trends of people living with HIV aged 50 and over: Estimates and projections for 2000-2020

BACKGROUND

The increasing numbers of people living with HIV (PLHIV) who are receiving antiretroviral therapy (ART) have near normal life-expectancy, resulting in more people living with HIV over the age of 50 years (PLHIV50+). Estimates of the number of PLHIV50+ are needed for the development of tailored therapeutic and prevention interventions at country, regional and global level.

METHODS

The AIDS Impact Module of the Spectrum software was used to compute the numbers of PLHIV, new infections, and AIDS-related deaths for PLHIV50+ for the years 2000-2016. Projections until 2020 were calculated based on an assumed ART scale-up to 81% coverage by 2020, consistent with the UNAIDS 90-90-90 treatment targets.

RESULTS

Globally, there were 5.7 million [4.7 million- 6.6 million] PLHIV50+ in 2016. The proportion of PLHIV50+ increased substantially from 8% in 2000 to 16% in 2016 and is expected to increase to 21% by 2020. In 2016, 80% of PLHIV50+ lived in low- and middle-income countries (LMICs), with Eastern and Southern Africa containing the largest number of PLHIV50+. While the proportion of PLHIV50+ was greater in high income countries, LMICs have higher numbers of PLHIV50+ that are expected to continue to increase by 2020.

CONCLUSIONS

The number of PLHIV50+ has increased dramatically since 2000 and this is expected to continue by 2020, especially in LMICs. HIV prevention campaigns, testing and treatment programs should also focus on the specific needs of PLHIV50+. Integrated health and social services should be developed to cater for the changing physical, psychological and social needs of PLHIV50+, many of whom will need to use HIV and non-HIV services.

Screening tools for HIV-associated neurocognitive disorders among adults living with HIV in sub-Saharan Africa: A scoping review

Background: People living with HIV are at risk of developing HIV-associated neurocognitive disorders (HAND) which adversely affects their quality of life. Routine screening of HAND in HIV care is recommended to identify subtle changes in cognitive functioning and allow for early interventions. However, HAND detection is rarely done in sub-Saharan Africa (SSA), partly due to a lack of adequately standardized screening tools. This review was conducted to identify the commonly used screening tools for HAND in SSA and document their psychometric properties and diagnostic accuracy.Methods:We searched Ovid Medline, PsycINFO and Web of Sciences databases for empirical studies published from 1/1/1980 to 31/8/2018 on HAND among adults living with HIV in SSA.Results:We identified 14 eligible studies, of which 9 were from South Africa. The International HIV Dementia Scale (IHDS) was the most frequently reported tool, being used in more than half of the studies. However most studies only reported the diagnostic accuracy of this and other tools, with specificity ranging from 37% to 81% and sensitivity ranging from 45% to 100%. Appropriate data on construct validity and reliability of tools was rarely documented. Although most tools performed well in screening for severe forms of HAND, they lacked sensitivity and specificity for moderate forms of HAND. NeuroScreen, one of the newer tools, yielded good diagnostic accuracy in its initial evaluation in South Africa (81% to 93% sensitivity and 71% to 81% specificity).Conclusions:This review identified a lack of adequately standardized and contextually relevant HAND screening tools in SSA. Most screening tools for HAND used in SSA possess inadequate psychometric properties and diagnostic accuracy. There is a need for further validation of existing tools and development of new tools to make them sensitive and specific enough to identify both severe and moderate forms of HAND in SSA.

Aging with HIV: what effect on mortality and loss to follow-up in the course of antiretroviral therapy? The IeDEA West Africa Cohort Collaboration

Background

Reporting mortality and lost to follow-up (LTFU) by age is essential as older HIV-positive patients might be at risk of long-term effects of living with HIV and/or taking antiretroviral therapy (ART). As age effects might not be linear and might impact HIV outcomes in the oldest more severely, people living with HIV (PLHIV) aged 50-59 years and PLHIV aged >60 years were considered separately.

Setting

Seventeen adult HIV/AIDS clinics spread over nine countries in West Africa.

Methods

Data were collected within the International Epidemiological Databases to Evaluate AIDS West Africa Collaboration. ART-naïve PLHIV-1 adults aged >16 years initiating ART and attending ≥2 clinic visits were included (N=73,525). Age was divided into five groups: 16-29/30-39/40-49/50-59/≥60 years. The age effect on mortality and LTFU was evaluated with Kaplan-Meier curves and multivariable Cox proportional hazard regressions.

Results

At month 36, 5.9% of the patients had died and 47.3% were LTFU. Patients aged ≥60 (N=1,736) and between 50-59 years old (N=6,792) had an increased risk of death in the first 36 months on ART (adjusted hazard ratio=1.66; 95% CI: 1.36-2.03 and adjusted hazard ratio=1.31; 95% CI: 1.15-1.49, respectively; reference: <30 years old). Patients ≥60 years old tend to be more often LTFU.

Conclusion

The oldest PLHIV presented the poorest outcomes, suggesting that the PLHIV aged >50 years old should not be considered as a unique group irrespective of their age. Tailored programs focusing on improving the care services for older PLHIV in Sub-Saharan Africa are clearly needed to improve basic program outcomes.

Sexual behavior and HIV risk across the life course in rural South Africa: trends and comparisons

There is limited information about sexual behavior among older Africans, which is problematic given high HIV rates among older adults. We use a population-based survey among people aged 15-80+ to examine the prevalence of sexual risk and protective behaviors in the context of a severe HIV epidemic. We focus on variation across the life course, gender and HIV serostatus to compare the similarities and differences of young, middle aged, and older adults. Younger adults continue to be at risk of HIV, with potential partners being more likely to have been diagnosed with an STI and more likely to have HIV, partner change is high, and condom use is low. Middle aged and older adults engage in sexual behavior that makes them vulnerable at older ages, including extramarital sex, low condom use, and cross-generational sex with people in age groups with the highest rates of HIV. We find insignificant differences between HIV positive and negative adults' reports of recent sexual activity. This study provides new information on sexual behavior and HIV risk across the life course in rural South Africa to inform HIV prevention and treatment programing.

Policy-maker attitudes to the ageing of the HIV cohort in Botswana

Background: The roll out of antiretroviral therapy in Botswana, as in many countries with near universal access to treatment, has transformed HIV into a complex yet manageable chronic condition and has led to the emergence of a population aging with HIV. Although there has been some realization of this development at international level, no clear defined intervention strategy has been established in many highly affected countries. Therefore we explored attitudes of policy-makers and service providers towards HIV among older adults (50 years or older) in Botswana. Methods: We conducted qualitative face-to-face interviews with 15 consenting personnel from the Ministry of Health, medical practitioners and non-governmental organizations involved in the administration of medical services, planning, strategies and policies that govern social, physical and medical intervention aimed at people living with HIV and health in general. The Shiffman and Smith Framework of how health issues become a priority was used as a guide for our analysis. Results: Amidst an HIV prevalence of 25% among those aged 50–64 years, the respondents passively recognized the predicament posed by a population aging with HIV but exhibited a lack of comprehension and acknowledgement of the extent of the issue. An underlying persistent ageist stigma regarding sexual behaviour existed among a number of interviewees. Respondents also noted the lack of defined geriatric care within the provision of the national health care system. There seemed, however, to be a debate among the policy strategists and care providers as to whether the appropriate response should be specifically towards older adults living with HIV or rather to improve health services for older adults more generally. Respondents acknowledged that health systems in Botswana are still configured for individual diseases rather than coexisting chronic diseases even though it has become increasingly common for patients, particularly the aged, to have two or more medical conditions at the same time. Conclusions: HIV among older adults remains a low priority among policy-makers in Botswana but is at least now on the agenda. Action will require more concerted efforts to recognize HIV as a lifelong infection and putting greater emphasis on targeted care for older adults, focussing on multimorbidity.

Retention in care among older adults living with HIV in western Kenya: A retrospective observational cohort study

BACKGROUND

Retention, defined as continuous engagement in care, is an important indicator for quality of healthcare services. To achieve UNAIDS 90-90-90 targets, emphasis on retention as a predictor of viral suppression in patients initiated on ART is vital. Using routinely collected clinical data, the authors sought to determine the effect of age on retention post ART initiation.

METHODS

De-identified electronic data for 32965 HIV-infected persons aged ≥15 years at enrolment into the Academic Model Providing Access to Healthcare program between January 2008 and December 2014 were analyzed. Follow-up time was defined from the date of ART initiation until either loss to follow-up or death or close of the database (September 2016) was observed. Proportions were compared using Pearson's Chi-square test and medians using Mann-Whitney U test. Logistic regression model was used to assess differences in ART initiation between groups, adjusting for baseline characteristics. Cox proportional hazards model adjusting for baseline characteristics and antiretroviral therapy (ART) status was used to compute hazard ratios. Kaplan-Meier survival function was used to compare retention on ART at 12, 24, and 36 months post ART initiation.

RESULTS

Of the total sample, 3924 (12.0%) were aged ≥50 years at enrolment. The median (IQR) age of young adults and older adults were 32.5 (26.6, 36.9) and 54.9 (51.7, 59.9) respectively. ART initiation rates were 70.5% among older adults and 68.2% among younger adults. Retention rates in care at 12, 24 and 36 months post ART initiation were 73.9% (95% CL: 72.2, 75.5), 62.9% (95% CL: 61.0, 64.7) and 55.4% (95% CL: 53.5, 57.3) among older adults compared to 69.8% (95% CL: 69.1, 70.4), 58.1% (95% CL: 57.4, 58.8) and 49.3% (95% CL: 48.6, 50.0) among younger adults (p <0.001). A higher proportion of older adults were retained in HIV care post ART initiation compared to younger adults, Adjusted Hazard Ratio (AHR): 0.83 (95% CI: 0.78, 0.87) though they were more likely to die, AHR: 1.35 (95% CI: 1.19, 1.52).

CONCLUSION

A higher proportion of older adults are initiated on ART and have better retention in care at 12, 24 and 36 months post ART initiation than younger adults. However, older adults have a higher all-cause mortality rate, perhaps partially driven by late presentation to care. Enhanced outreach and care to this group is imperative to improve their outcomes.

The growing burden of noncommunicable disease among persons living with HIV in Zimbabwe

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Objectives:

We aim to characterize the future noncommunicable disease (NCD) burden in Zimbabwe to identify future health system priorities.

Methods:

We developed an individual-based multidisease model for Zimbabwe, simulating births, deaths, infection with HIV and progression and key NCD [asthma, chronic kidney disease (CKD), depression, diabetes, hypertension, stroke, breast, cervical, colorectal, liver, oesophageal, prostate and all other cancers]. The model was parameterized using national and regional surveillance and epidemiological data. Demographic and NCD burden projections were generated for 2015 to 2035.

Results:

The model predicts that mean age of PLHIV will increase from 31 to 45 years between 2015 and 2035 (compared with 20–26 in uninfected individuals). Consequently, the proportion suffering from at least one key NCD in 2035 will increase by 26% in PLHIV and 6% in uninfected. Adult PLHIV will be twice as likely to suffer from at least one key NCD in 2035 compared with uninfected adults; with 15.2% of all key NCDs diagnosed in adult PLHIV, whereas contributing only 5% of the Zimbabwean population. The most prevalent NCDs will be hypertension, CKD, depression and cancers. This demographic and disease shift in PLHIV is mainly because of reductions in incidence and the success of ART scale-up leading to longer life expectancy, and to a lesser extent, the cumulative exposure to HIV and ART.

Conclusion:

NCD services will need to be expanded in Zimbabwe. They will need to be integrated into HIV care programmes, although the growing NCD burden amongst uninfected individuals presenting opportunities for additional services developed within HIV care to benefit HIV-negative persons.

Effect of age and level of education on neurocognitive impairment in HIV positive Zambian adults

OBJECTIVE

Older age and lower education levels are known to be associated with worse neurocognitive (NC) performance in healthy adults, and individuals with HIV infection may experience accelerated brain/cognition aging. However, higher education may possibly protect against HIV-associated neurocognitive disorders (HAND). The aim of the current cross-sectional study was to assess the effect of age and education in an HIV-1 clade C infected adult population in urban Zambia.

METHOD

Demographically corrected Zambian norms on a neuropsychological (NP) test battery were used to correct for normal age and education effects. The study assessed 286 HIV positive (+) males (37.1%) and females (62.9%) with a mean age of 41.35 (SD = 8.56) and mean years of education = 10.16 (SD = 2.18). A comprehensive NP test battery was used to assess cognitive domains frequently affected by HIV: attention/working memory, learning/and delayed recall, executive function, verbal fluency, processing speed, verbal and visual episodic memory, and fine motor skills.

RESULTS

In younger HIV+ Zambians, higher education evidenced protective effects against NC impairments overall, and for the specific domains of executive functions, learning and speed of information processing. Impairment scores did not support accelerated overall brain aging although the restricted age range and relative youth of our total sample may have precluded detection of such tendencies.

CONCLUSIONS

The present study raises the need to investigate factors that could be implicated in the poor neurocognitive performance among the younger, less educated HIV+ individuals in Zambia. (PsycINFO Database Record