Aging with HIV in Sub-Saharan Africa

Mark Brennan-Ing, PhD, is Director of Research and Evaluation at the Brookdale Center for Healthy Aging at Hunter College, City University of New York. Dr. Brennan-Ing's research focuses on psychosocial issues affecting persons living with HIV and older sexual minority and gender diverse adults. They are Past-President of the State Society on Aging of New York (SSANY), a Fellow of the Gerontological Society of America (GSA), a Fellow of Division 44 (Psychology of Sexual Orientation and Gender Diversity) of the American Psychological Association, and past Board Member of the New York Association on HIV over Fifty (NYAHOF). They were the Principal Convener for GSA's HIV/AIDS and Aging interest group, a member of the American Society on Aging's LGBT Aging Information Network Leadership Council, and 2016 Chair of the American Psychological Association's Committee on Sexual Orientation and Gender Diversity. They were an invited member of the National Institutes of Health (NIH) Office of AIDS Research Working Group on HIV and Aging in 2011. Dr. Brennan-Ing has been recognized for their work by the Hunter-Brookdale Center on Aging, Pride Senior Network, and the New York State Office for the Aging. In 2017 they received the Walter M. Beattie Award from SSANY. Dr. Brennan-Ing was the lead editor of Older Adults with HIV: An In-depth Examination of an Emerging Population (2009) and the 2016 volume HIV and Aging: Interdisciplinary Topics in Gerontology and Geriatrics (vol. 42), which received a "High Commendation" from the British Medical Association. They have authored over 100 peer-reviewed articles, chapters, and books.

Kristen E. Porter, PhD, MAc, LAc, began working in the HIV field in 1994, first as a clinician, then as a nonprofit executive director of an HIV/AIDS integrative medicine clinic. After receiving her PhD in gerontology from University of Massachusetts Boston, she completed postdoctoral training at ACRIA's Center on HIV and Aging in New York (2015-2017). During that time, she was part of an international team of collaborating researchers on HIV and aging in sub-Saharan Africa. Her conference presentations on the topic include "Aging with HIV. Transgender Older Adults: Challenges, Resources, Resilience" (2019; 9th Annual LGBT Elders in an Ever Changing World, Salem State University, Salem, MA), "Older Adults with HIV in South Africa: Experiences of Intimate Partner Violence" (2016; 68th Annual Scientific Meeting of the Gerontological Society of America, New Orleans, LA), and "Complementary and integrative health (CIH) use in older adults with HIV" (2016; 21th International AIDS Conference, Durban, South Africa). Her research has centered on resilience among those aging with HIV, as well as sexual and gender minorities, and can be found in peer-review journals (such as Journals of Gerontology, The Gerontologist, Research on Aging, Clinical Gerontologist, Journal of Applied Gerontology) and the book Transgender and Gender Nonconforming Health and Aging (Ed. Hardacker et al., Springer, 2019).

Jennifer E. Kaufman, MPH, is a Senior Research Associate at the Brookdale Center for Healthy Aging at Hunter College, City University of New York. Her current work focuses on older people with HIV, sexual and gender minorities, and health messaging and technology access for older adults. Her interests also include health policy and the economics of aging, and her research on the wellbeing of older adults has covered a range of topics, such as creative aging programs, family caregiving, and racial disparities in the economic effects of dementia. Ms. Kaufman has an extensive editorial background at academic presses, journals, and textbook publishers, and in education and social policy research. She holds a master's degree in public health policy and management from the Graduate School of Public Health and Health Policy,

 With the development of effective antiretroviral therapies (ART) in the mid-1990s, HIV became a treatable although serious condition, and people who are adherent to HIV medications can attain normal or near-normal life expectancies. Because of the success of ART, people 50 and older now make up a majority of people with HIV in high-income countries and other places where ART is accessible. The aging of the HIV epidemic is a global trend that is also being observed in low- and middle-income countries, including countries in sub-Saharan Africa, where the greatest number of older people with HIV reside (3.7 million). While globally over half of older adults with HIV are in sub-Saharan Africa, we have little information about the circumstances, needs, and resiliencies of this population, which limits our ability to craft effective policy and programmatic responses to aging with HIV in this region. At present, our understanding of HIV and aging is dominated by information from the U.S. and Western Europe, where the epidemiology of HIV and the infrastructure to provide social care are markedly different than in sub-Saharan Africa. Aging with HIV in Sub-Saharan Africa addresses this gap in our knowledge by providing current research and perspectives on a range of health and psychosocial topics concerning these older adults from across this region. This volume provides a unique and timely overview of growing older with HIV in a sub-Saharan African context, covering such topics as epidemiology, health and functioning, and social support, as well as policy and program implications to support those growing older with HIV.

There are very few published volumes that address HIV and aging, and this is the first book to consider HIV and aging in sub-Saharan Africa. Most publications in this area focus on HIV and aging in Uganda and South Africa. This volume broadens the scope with contributions from authors working in West Africa, Botswana, and Kenya. The range of topics covered here will be useful to professionals in a range of disciplines including psychology, epidemiology, gerontology, sociology, health care, public health, and social work.

1.       Foreword

Mark Brennan-Ing

2.       Epidemiology of HIV in the older African population

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 people's 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 people's 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

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 people's 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 people's 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

8.       Mental health in older people living with HIV in sub-Saharan Africa: A review and future research recommendations

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 country's 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.