Mutevedzi, PC; (2013) Old Age Health and HIV in a Rural Area with High HIV Prevalence and Incidence: What is the Impact of Enhanced Access to Antiretroviral Treatment? Doctoral thesis (PhD), UCL (University College London).

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Abstract

The widespread roll-out of antiretroviral therapy (ART) has resulted in a decline of HIV-related deaths; as a result the HIV positive population is rapidly ageing with improved survival of HIV positive adults on ART. In sub-Saharan Africa, including South Africa, where older adults comprise a significant proportion of the total population, health services face the complexities of an ageing population and HIV. The aim of this PhD study is to inform understanding of issues relating to older adults, aged 50 years or more, HIV infection and ART, who are resident in Northern KwaZulu-Natal, South Africa. Data from the cross-sectional Wellbeing of Older People Study (WOPS), including 422 older adults and nested within the demographic surveillance system, show that HIV positive older adults receiving ART for >1 year had less chronic morbidity than HIV negative older adults despite having higher IL6 and hsCRP levels. To quantify the cause-specific morbidity burden at the time of initiating ART, data on 1 409 adults aged ≥16 years obtained from the ART Clinical Cohort show that chronic morbidity at time of ART initiation burden and HIV-associated morbidity was more common in older than younger (16-49 years old) adults. Data from the HIV Treatment and Care programme, linked to an electronic Hospital Information database (n=8598 adults aged ≥16 years) show that older adults had a lower hospitalisation rate, but higher case fatality rates, than younger adults. In the HIV treatment and Care programme, including 8846 overall, in the first year of ART, mortality was higher in older than younger adults, but rates in the two groups were similar thereafter. Older adults had a blunted immunological but superior virological response. All-cause mortality risk increased with a decline in CD4 cell count and unsuppressed viral load. Further detailed data from the ART Clinical Cohort showed that, in both age groups, the contribution of multiple co-morbidity to early mortality was high. The results presented here contribute towards evidence required to understand issues surrounding the health of older adults in the context of high HIV prevalence and incidence with widespread availability and access to ART and provide knowledge required for evidence-based health planning for the ageing HIV cohort. The thesis concludes with a discussion of the implications for health service development and future research.

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