For decades, public health efforts across sub-Saharan Africa have focused on HIV prevention, testing and treatment campaigns on children and women of reproductive age, overlooking the population at older ages.
At present, the high success of antiretroviral therapy (ART) campaigns, together with the continuous efforts to achieve the UNAids 95-95-95 HIV targets — that 95 per cent of people with HIV know their status, 95 per cent of those are on treatment and 95 per cent of those have suppressed viral loads — have reduced the HIV treatment gap in many African countries. In turn this has dramatically increased the life expectancy of people living with HIV.
One consequence of this is that the HIV epidemic is increasingly affecting older people. Due to this increase in life expectancy in the population living with HIV, the HIV epidemic has experienced an ageing process.
However, most HIV programmes and studies still neglect the population over 50 years of age. The immediate consequence is that older adults, especially women past childbearing age, are often invisible in surveillance data, overlooked in prevention messaging and under-represented in care strategies.
Few HIV interventions are tailored to this group, even though they face unique risks. This blind spot has serious consequences for the health and well-being of a growing and vulnerable population.
We have worked in the past years to better understand the ageing process of the HIV epidemic, not only on the growing number of people living with HIV, but also on explaining the risks of new HIV infections in the older population.
In response to this dearth of data, we studied the changes in the HIV epidemic in a group of older people over two waves of data collection (2013-16 Wave 1; 2019-22 Wave 2) and across nearly a decade.
The study, a sub-study of the AWI-Gen study in Africa, followed over 7,000 adults aged 40 and older in four locations. Three were in South Africa — the urban setting of Soweto in the country’s industrial heartland and the rural setting of Bushbuckridge in the north-east of the country and Dikagale, Mamabolo and Mothiba in the north — and one in Nairobi slums in Kenya.
These settings allow for comparison of east and southern Africa, the two African regions with higher prevalence of HIV. At the same time, it permits a comparison between rural and urban settings.
We were able to assess the number of people living with HIV, the number of new infections and the social factors driving the HIV transmission. We did this by doing HIV tests and asking participants if they’d ever been tested for HIV, whether they knew their HIV status and whether they were receiving ART.
We found that one in five adults (22 per cent) in the study were living with HIV (that is, they were infected with HIV). This rate stayed high across both time points. We also observed that new infections were happening in this older population, especially in widows, rural residents and those with no formal education.
This shows that, even as treatment access improved, major disparities persisted. And older adults are still acquiring HIV, often because the public campaigns for HIV leave them out.
The conclusion that can be drawn from our findings is that the world needs to stop seeing HIV as only a “young person’s disease”. The narrative needs to change, as must the response. Ageing with HIV is now a global public health reality — especially in sub-Saharan Africa — and the HIV response must evolve to reflect that.