1. Foreword
Mark Brennan-Ing
2. Epidemiology of HIV in the older African population
F. Xavier Gomez-Olive
The HIV epidemic has been associated with a younger population, but this no longer holds true. Before effective treatment was available, AIDS mortality in sub-Saharan Africa was rising, peaking in the early 2000s. Then, with the introduction of antiretroviral therapy, life expectancy of people living with HIV increased. Their survival resulted in a higher prevalence of HIV in the over-50 population, creating a double burden of diseases, where HIV coexists with noncommunicable conditions. This double burden places extra stress on an already weak primary health system, especially in rural settings. Older people are also acquiring HIV. Prevention campaigns mainly target young people. People over 50 may therefore engage in high-risk sexual behavior that exposes them to infection, resulting in higher than expected HIV incidence. It is crucial to understand how older people perceive their risk of contracting HIV in order to institute effective preventive measures.
3. Multiple chronicities: Aging bodies, wellbeing, and chronic HIV in Eastern Africa
Josien de Klerk
The concept of multiple chronicities is used to argue that living with chronic HIV is not a singular experience. Building on ethnographic work in two rural settings (Tanzania) and an urban setting (Kenya), this chapter frames older peoples living with the virus as a social experience, blurring the distinction between being infected and being affected by loss and prolonged caregiving. In East African where HIV is endemic, older peoples personal and family histories with the virus shape the multiplicity of chronic HIV. The embodied experience of chronic HIV for older people is not only about how the virus behaves in the older body but also about the management of traumatic memories of caregiving and loss. HIV interplays with other chronic conditions, such as noncommunicable diseases and economic conditions. The presentation of a senior service model that acknowledges HIV as multiple chronicity exemplifies how models of HIV care could be developed in endemic contexts.
4. Comorbid conditions occurring in older adults on antiretroviral therapy (ART) in Botswana: A retrospective cross-sectional cohort study of patient data
Kabo Matlho
Although people over the age of 50 account for more than 20% of those living with HIV in Botswana, they are largely underrepresented in HIV research and tailored interventions. Yet the interaction of aging and HIV may involve an increased risk for and exacerbation of chronic illnesses such as tuberculosis (TB); cardiovascular, kidney, and liver diseases; diabetes; hypertension; and cancers, as well as cognitive decline. These comorbidities complicate treatment and potentially increase mortality. This study gauged the existence and magnitude of comorbidities within the aging HIV cohort in Botswana using data from patients age 35 and older who were on first-line antiretroviral therapy. The data show a higher rate of specific comorbidities in adults 50 and older compared with those age 35-49. TB was particularly prevalent in older men, and hypertension was most prevalent among older women. Multimorbidity is pronounced among those aging with HIV in Botswana. Guidelines and policies need to adapt to the changing demographics and evolving challenges.
5. Expectations of health and illness in older age through the lens of the HIV-epidemic in Uganda
Joseph Mugisha & Janet Seeley
We focus on how the experience of living through the HIV epidemic shapes older peoples responses to (and fears about) chronic illness and health emergencies such as the COVID-19 pandemic. Using the example of Uganda, we examine the ways in which the particular time people encountered HIV in their lives affects their understanding and perception of ill health and concerns about the risks HIV continues to pose. For example, older people who nursed their relatives through HIV-related illness prior to the availability of antiretroviral therapy (ART) continue to see HIV as a death sentence; those living with HIV and on ART, schooled in the discipline of taking their tablets daily, doubt the seriousness of conditions for which there is a curative treatment. We draw on the work of Leventhal and colleagues (2016) and concepts from the Common-Sense Model of Self-Regulation of how the response to information on an asymptomatic chronic condition may be shaped by peoples experience of other conditions, such as HIV.
6. Sexual behavior among older adults with HIV in sub-Saharan Africa
Mark Brennan-Ing, Jennifer E. Kaufman, Kristen Porter, Catherine MacPhail, Janet Seeley, S. E. Karpiak, Francois Venter, Monica Kuteesa, Louise Geddes, & Joel Negin
We have little information about sexual health among older adults with HIV (OAH) in sub-Saharan Africa, limiting our ability to mount effective secondary prevention efforts. This information is vital since adults remain sexually active well into old age and may be a vector for HIV and other sexually transmitted infections. We used data from OAH from Uganda (N=101) and South Africa (N=108) and made comparisons on sexual health and risk behaviors. Substantial proportions of OAH in both countries were sexually active, but there were significant differences in HIV disclosure and condom use. Findings suggest that secondary HIV prevention for OAH requires greater attention. Differences in sexual activity and sexual risk among OAH in South Africa and Uganda point to cultural and social influences, warranting caution against broad generalizations about OAH in sub-Saharan Africa. There is a need for tailored policy and programmatic solutions to address sexual health.
7. Ask those who are ahead about a buffalo: Well-being of grandparents with HIV in Uganda and South Africa
Kristen Porter, Catherine MacPhail, Janet Seeley, S. E. Karpiak, Francois Venter, Monica Kuteesa, Louise Geddes, Joel Negin, & Mark Brennan-Ing
Sub-Saharan Africa continues to be the region most profoundly affected by HIV/AIDS in the world. The United Nations (April 2019) reported that of 98 countries, it is most common for older adults to be living with younger children in countries of sub-Saharan Africa. Older sub-Saharan African adults are frequently involved in grandchild care, but little is known on how this impacts the grandparents well-being. While more is known about grandparents caring for HIV-positive grandchildren (i.e., AIDS orphans), the impact of caring for grandchildren on HIV-positive grandparents is nascent. This chapter draws upon a cross-sectional study of older grandparents living with HIV in Uganda and South Africa (N=209). Using a stress process framework, the role of potential stress factors (e.g., cohabitating with grandchild, comorbidities, health-related quality of life) on psychological well-being is examined.
8. Mental health in older people living with HIV in sub-Saharan Africa: A review and future research recommendations
Charlotte Bernard & Nathalie de Rekeneire
In sub-Saharan Africa, as elsewhere, increasing use of HIV medical services and antiretroviral therapy (ART) mean that HIV is now considered a chronic disease. With aging, people living with HIV experience not only physiological complications but also neuropsychological and social issues. Two mental health disorders are mainly observed in this population: HIV associated neurocognitive disorders (HAND) and depression. The prevalence of HAND remains high despite ART use, and the aging process may exacerbate it. Both HAND and depression negatively affect ART adherence, HIV outcomes, and quality of life. These public health issues could cause significant burden on healthcare systems and human resources, especially in sub-Saharan Africa, the world region least prepared to deal with HIV. This chapter presents a review of the current knowledge about neurocognitive impairment and depression in older people living with HIV in sub-Saharan Africa. We then propose recommendations for future research.
9. The support keeps me strong: Social support of older people living with HIV in South Africa
Catherine MacPhail, Megan Mattingly, Victor Minichiello, Francois Venter, Stephen Karpiak, & Mark Brennan-Ing
Much is known of the experience of older South Africans as caregivers and resources for younger generations affected by HIV, but less is known of social support experienced by those aging with HIV. This chapter presents data from qualitative interviews conducted with 15 South Africans over 50 years of age living with HIV in inner-city Johannesburg. Contrary to reports of stigma and lack of support in developed countries, the majority experienced amplified social and practical support within their families, if not outside of them, particularly from adult children. Women were additionally supported by siblings and men particularly by their spouses. Practical and physical support in daily tasks and other activities specifically associated with HIV was more commonly mentioned than emotional support. At the same time, participants noted that their own caregiving roles did not diminish. In particular, they continued to financially support extended family members, and women remained a significant source of domestic labor.
10. A comparison of social support resources among older adults with HIV in Uganda and South Africa
Mark Brennan-Ing, Jennifer E. Kaufman, Kristen Porter, Catherine MacPhail, Janet Seeley, S. E. Karpiak, Francois Venter, Monica Kuteesa, Louise Geddes, & Joel Negin
Research on older adults with HIV (OAH) finds they have high rates of comorbid conditions in addition to HIV, suggesting they will require increasing assistance from their informal social networks. But data are scarce on social network dynamics of OAH in sub-Saharan Africa. To address this gap, we examined social support resources among OAH from Uganda (N=101) and South Africa (N=108). There are significant differences between OAH in these two countries in the composition of their social networks, support provided, and perceptions of social support sufficiency. Despite high levels of informal support in both countries, sizable proportions felt that support from family and friends was insufficient to meet their needs. Given the significant differences between countries, research is needed to better understand the cultural/societal factors affecting social care among older adults with HIV in sub-Saharan Africa. Further, policy and program initiatives to meet unmet support needs are sorely needed.
11. Reprogramming HIV prevention and service provision for older adults
Jepchirchir Kiplagat
People age 50 and older represent 12% of people living with HIV (PLWH) in western Kenya, and the number is expected to rise. The situation calls for tailoring approaches to both prevention and care. To achieve the countrys goal of 80% of PLWH knowing their status, there is an urgent need to include older adults in prevention messaging and testing services. Door-to-door HIV testing and counselling would decrease travel and transportation barriers for older adults. In terms of care, it is challenging to manage HIV in addition to comorbid conditions that are common among older adults. When services are fragmented, seeking care for multiple conditions is expensive and makes adherence more difficult. In addition, both neurocognitive disorders and visual impairment affect medication adherence among older people particularly those living alone. Meeting the needs of older adults will require transforming healthcare facilities to integrate services and sharing information between providers.
12. Policy innovations for an aging HIV epidemic in sub-Saharan Africa
Ruth Finkelstein
The population of older adults with HIV is approaching four million and will continue to grow in the foreseeable future. While the aging of HIV in sub-Saharan Africa and elsewhere represents a success story for antiretroviral therapy, this success also brings challenges, as these older adults have increasing needs for health and social care due to multimorbidity resulting from HIV and age-related chronic conditions. The aging of people with HIV in this region is further complicated by the lack of financial, healthcare, and community-based resources that support healthy aging, like those available in high-income countries. In this chapter, we outline several policy initiatives needed to support older adults with HIV in sub-Saharan Africa to meet the challenges of this aging epidemic.
