Ageing Faster With AIDS in Africa 

By Edward J Mills, Anu Rammohan, and Niyi Awofeso, The Lancet 

April 4, 2011 

Africa 

As the AIDS epidemic matures, evidence is emerging that poorly managed HIV infection exacerbates ageing diseases, leading to increased morbidity and mortality, and that exacerbated chronic diseases should now be considered AIDS-related.(1) Cohort evaluations indicate that non-AIDS cancers, pulmonary diseases, intracranial haemorrhage, osteoporosis, and age-related blindness, which might previously have been considered of low importance due to low prevalence, are becoming major causes of reduced quality of life and causes of death.(1) Thanks to antiretroviral therapy, a person diagnosed HIV-positive and aged 20 years in the developed countries can expect to be alive well into their sixties,(2) and these settings are well equipped to deal with an ageing HIV-positive population with the availability of specialised care.  

For the vast majority of people living with HIV/AIDS, living in Africa, the focus of attention to date has been on the provision of emergency care for the most vulnerable, with children, mothers, and severely immunocompromised patients at the forefront of services.(3) Few service providers have planned for an ageing African HIV-positive population because no one expected this group to survive to older age. However, the proportion of elderly people in Africa infected with HIV/AIDS is increasing.(3-5) This increase brings both good and bad news: good news because increased access to treatments means that patients are living with longer life expectancy; bad news because meeting the complexities of geriatric care for HIV-infected adults will further challenge overwhelmed health systems.  

In the first report addressing the size of the epidemic for older adults (>50 years) in Africa, Negin and Cummings extrapolated data from UNAIDS and Demographic and Health Survey (DHS) reports to estimate that about 3 million elderly individuals in Africa are living with HIV infection, approximately 14% of all HIV infections.(3) The estimated prevalence of HIV infection in this demographic across sub-Saharan Africa is 4%, not very different from the prevalence in the general adult population (5%), with Zimbabwe having the largest prevalence of about 20%.  

Kenya is the only African nation with two full nationally representative DHS datasets for older adults, 2003 and 2008—09.(4, 5) The 2003 data documented male HIV prevalence as 4·6% for the 15—49 year age-group, and 5·7% for the 50—54 year age-group. The prevalence of HIV notification in men aged 50—54 years almost doubled between 2003 and 2008 (from 5·7% to 9·1%), while younger cohorts were generally static or declining in prevalence. HIV prevalence was highest in the wealthiest quintile and increased in both cohorts for the two survey periods. Further, over 60% of men aged 50—54 years who tested positive lived in rural areas. Yet the bulk of HIV services are in urban areas of Africa and target younger cohorts from poorer wealth quintiles.  

Although several large cohort analyses have examined ageing as a risk factor for mortality, no estimates on mortality rates or causes of death are available.(6) Yet important reports are emerging. A recent community mortality analysis from Kenya found that about 17% of mortality above the age of 50 years was attributable to AIDS as determined by verbal autopsy, with no ascertainment of AIDS-exacerbated deaths.(7)  

Older people are neglected in the AIDS response. Little concern is attached to sexually active African older adults; thus social marketing for prevention addresses cross-generational sex and not within-population sex. Although monitoring of the AIDS epidemic has been inconsistent, it has focused predominantly on country and UN reports of those aged 15—49 years with no reports addressing those aged 50 years and older.(8) In most sub-Saharan African settings, life expectancy hovers between 44 and 51 years; thus 50 years and above qualifies as elderly.(9) Finding estimates of the size of this population and their specific disease presentation is challenging.  

In Africa, where the burden of HIV is higher than in any other setting, older Africans are more likely to reside in rural areas that are outside medical service areas. Local medical centres often lack access to common age-related therapies, such as cardiovascular and neurological services, conditions that are exacerbated by HIV infection; and rehabilitation services are almost consistently non-existent. In epidemic settings, this population can be particularly disadvantaged because the population often has orphaned young children, might not have children alive to support adults, and has limited income.(10)

The perception that HIV is a problem only for young people and that older Africans are not at risk of HIV infection needs to be dispelled. Older adults in Africa are important members of village and town economies as elders and caregivers. Providing improved availability of AIDS care, that includes diseases of advanced age, and improving the social safety-net will make these people less vulnerable to AIDS complications and better able to perform their societal roles. Creating awareness of HIV and ageing might help with prevention and treatment programmes and issues of stigma, just as have been started in the USA with National HIV/AIDS and Aging Awareness day (Sept 18, 2010).(11) As the AIDS epidemic matures, this is a crucial time to understand the size of this population and make available medical care that addresses their disease-specific needs.

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