Transcript Slides - Division of Gender, Sexuality, and Health
Slide 1
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 2
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 3
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 4
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 5
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 6
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 7
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 8
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 9
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 10
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 11
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 12
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 13
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 14
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 15
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 16
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 17
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 18
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 19
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 20
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 21
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 22
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 23
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 24
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 25
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 26
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 27
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 28
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 29
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 30
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 31
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 32
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 33
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 34
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 35
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 36
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 37
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 38
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 39
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 40
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 41
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 42
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 43
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 44
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 45
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 46
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 47
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 48
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 49
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 50
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 51
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 52
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 53
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 54
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 55
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 56
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 2
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 3
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 4
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 5
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 6
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 7
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 8
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 9
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 10
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 11
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 12
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 13
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 14
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 15
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 16
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 17
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 18
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 19
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 20
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 21
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 22
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 23
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 24
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 25
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 26
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 27
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 28
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 29
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 30
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 31
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 32
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 33
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 34
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 35
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 36
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 37
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 38
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 39
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 40
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 41
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 42
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 43
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 44
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 45
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 46
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 47
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 48
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 49
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 50
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 51
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 52
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 53
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 54
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 55
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you
Slide 56
HIV/AIDS and older
persons
History, prevalence and impact
in South Africa
Sebastiana Kalula
Institute of Ageing in Africa
Groote Schuur Hospital
University of Cape Town
South Africa
The HIV/AIDS epidemic
Two thirds (67%) of the 33 million
people worldwide living with HIV and
AIDS are in sub-Saharan Africa
Heterosexual transmission is the
predominant mode of the spread of the
HIV virus in the sub-continent
Other specific modes of transmission
are sex work, intravenous drug use and
male sex
UNAIDS, 2009
Factors contributing to spread of HIV:
Poverty
Social inequality and political instability
High levels of sexually transmitted
infections
Low status of women
Sexual violence
High mobility levels (migrant labour)
Limited and inequitable access to quality
medical care
Poor leadership in response to the
epidemic
History of HIV and AIDS in
South Africa
South Africa has had a turbulent political
past
The epidemic affects people from all
walks of life
Early history of HIV in the country
largely confined to homosexual men
AIDS was viewed as a homosexual
disease
Cont.
Wider population thus largely ignored
the risks of contracting the virus
Apartheid government excused itself
from responding proactively
Haemophiliacs became infected
through infected blood and blood
products
Moralisation of the epidemic
Cont.
Black South Africans were first
diagnosed with the disease in 1987
(among mine workers)
Mine workers are vulnerable to HIV
infection due to high levels of mobility
(migrant labour)
The industry is largely dependent on
local and regional migrant workers
Operates in inhospitable locations
family separation and isolation
Cont.
In the 1990s the South African epidemic
was linked to the wider continental
epidemic with dominant strains of HIV
previously found in Central Africa
Areas of high prevalence were located
along long-haul truck routes leading into
bordering countries
Heterosexual transmission has become
by far the dominant transmission route
First national response
Early nineties saw AIDS start to make its
way onto the national agenda in South
Africa
Creation of the National AIDS
Coordinating Committee of South Africa
(NACOSA) in 1992
In the turbulent political climate many
groups attached conspiracy theories, and
unfounded political and racial
motivations to the spread of HIV
Percentage
Prevalence antenatal clinics
40
30
20
10
0
20
19
02
99
92
90
19
19
Increased prevalence antenatal clinics
Increased infant mortality
No Mother-to-Child Transmission
Prevention Programme (MTCTP)
Cont.
In 2001 the South African
government implemented an MTCTP
programme after being taken to court
In 2003 it produced an Operational
Plan for the rollout of antiretroviral
treatment, with treatment starting in
2004
Social and economic impact
In 2009 average life expectancy in
SA was 54 years; without AIDS, it
is estimated it would have been 64
Between 1990 and 2003 when HIV
prevalence in SA increased
dramatically, the country fell by 35
places in the Human Development
Index
Stats SA, 2009
Population ageing South Africa
Total population
49.3 M
Population 60+
3.9 M
% total population
7.5 %
Projected number
and % by 2050
6.4 million (14.2 % )
Population 80+ in
2009
Projected % by
2050
Stats SA, 2009
9 % of older population
29 % of older population
UNDP, 2006
Ethnic distribution of total population
and population age 60+
80
70
60
50
Percent 40
Total
30
60+ years
20
10
0
Black
Coloured
Indian/
Asian
White
Source: StatsSA, 2009
Population ageing
Size of black older population will
increase dramatically
Size of white older population will
diminish proportionately
Black older persons:
Disadvantaged across the life course
Largely poor
Lack medical insurance
Dependent on public health and welfare
services
Population ageing
South Africa faces accelerated
population ageing
HIV/AIDS epidemic
high mortality
in infants, children, young adults
Diminished work force and reduced tax
base
Diminished support for the now young
grandmothers, who will grow old
HIV prevalence in South Africa
Three national population-based surveys
conducted by the Human Sciences
Research Council (HSRC)
HIV prevalence in the age group 2+
years in South Africa was 11.4% in
2002, 10.8% in 2005 and 10.9% in
2008
Prevalence is heterogeneous in South
Africa’s provinces, ranging from 15.8%
in KwaZulu-Natal to 3.8% in the
Western Cape
HIV prevalence (%)
HIV prevalence in 15- 49 age group by province,
South Africa, 2008
30
25
20
15
10
5
0
25.8
23.1
18.5
17.7
15.2
15.2
13.7
9
5.3
KZN
MP
FS
NW
GP
EC
LP
NC
WC
Province
Shisana et al., 2008
HIV prevalence, by sex and age, South Africa
2008
HIV prevalence (%)
35
30
25
20
Males
15
Females
10
5
0
+
60
-5
55
-5
50
-4
45
-4
40
-3
35
-3
30
-2
25
-2
20
14
-1
15
2-
9
4
9
4
9
4
9
4
9
Age group (years)
Shisana et al., 2008
Factors predisposing to HIV
infection:
Early sexual debut – entry into sexual
relationships before age 15 years
Older sexual partners (five or more years)
Unequal power dynamics, with vulnerable
young girls and wives unable to negotiate
condom use
High turnover of partners, or multiple
partners
In 2009, SA had an estimated overall
HIV prevalence of 10.6% and 5.21
million people are living with HIV
In age group 15-49 years, 17% are
HIV positive
In 2009, estimated new HIV infections
were 413 000, 59 000 of which were
among children
There are approximately 1.91 million
AIDS orphans in the country
Stats SA, 2009
Prevalence in older persons
Prevalence rates in the older age
group are as high as in the general
population
Rates compare to a small number of
countries in Eastern and Southern
Africa where surveys have been done
Prevalence rates of HIV/AIDS infection in South
Africa for the age ≥ 50 years: 2005 and 2008
(percentages)
Age group
2005
2008
Male
Female
Male
Female
50 – 54
14.2
7.5
10.4
10.2
55 – 59
6.4
3.0
6.2
4.7
60+
4.1
3.7
3.5
1.8
National prevalence
10.8% (2+ years)
10.9 (2+ years)
Shisana et al., 2008
Most-at-risk
populations
(MARPs)
N
HIV + %
African female 20-34
1 395
32.7
African males 25-49
944
23.7
Males 50+ years
946
6.0
MSM
86
9.9
High-risk drinkers
965
13.9
Recreational drug users
490
10.8
People with disabilities
458
14.1
Shisana et al., 2008
Behavioural determinants
of HIV
Condom use at last sex by age group and sex, South
Africa 2002, 2005, and 2008
Condom use at
last sex (%)
100
80
60
40
20
0
Male
Female
15-24 years
Male
Female
25-49 years
Male
Female
>50 years
2002
2005
2008
Condom use by marital status and age
70
60
50
Percent
40
15-24
30
25-49
20
50+
10
0
Single
Married or
Cohabit
Widowed Divorced or
separated
Shisana et al., 2005
Condom use at last sex (%)
Condom use at last sex by MARPs, South Africa 2002,
2005 and 2008
2002
2005
2008
80
60
40
20
0
African females
20-34 years
African males
25-49 years
M ales 50+ years
High-risk drinkers Recreational drug
users
MARPs with multiple sexual partners, South
Africa 2002, 2005, and 2008
Multiple partners (%)
30
25
20
15
10
5
0
African females
20-34
African males
25-49
Males 50+
High-risk
drinkers
Recreational
drug users
Age (years) and gender
2002
2005
2008
Awareness of HIV status in the last 12 months, by
sex of respondent, South Africa 2005 and 2008
Awareness of HIV status (%)
35
30
25
20
15
10
5
0
Male
Female
Total
2005
2008
Respondents who underwent an HIV test
in last 12 months, and received their
results, South Africa 2005 and 2008
2005
2008
Sex
n
%
n
%
Male
604
93.9
877
94.4
Female
1 132
92.0
1 611
97.2
Total
1 736
89.9
2 488
96.2
Correct knowledge about prevention of sexual
transmission of HIV and rejection of major
misconceptions of HIV transmission
Correct HIV knowledge
(%)
2005
50
40
30
20
10
0
Males
Females
15-24 years
Males
Females
25-49 years
Males
>50 years
Females
2008
Correct knowledge about prevention of sexual transmission
of HIV and rejection of major misconceptions of HIV
transmission by MARPs, South Africa 2005 and 2008
Correct HIV knowledge (%)
2005
2008
50
45
40
35
30
25
20
15
10
5
0
Afri
Afri
Mal
can
es 5
can
fem
0+
mal
ales
es 2
5-49
20-3
4
Hig
h-ri
s
Rec
re a
tion
k dr
al d
ink e
rug
rs
use
rs
Exposure to HIV communication programmes
SA government has HIV/AIDS
communication programmes and
numerous NPOs implement such
programmes
Communication is still poor among
some high risk groups
Less than half of all adults over 50 are
reached by any national programme
Shisana et.al., 2008
Reach of HIV and AIDS communication by
age, South Africa 2005 and 2008
2005
Age
2008
N
%
N
%
Youth (15-24)
5 331
86.3
4 214
90.2
Adults (25-49)
6 429
77.8
5 626
83.6
Adults (≥ 50)
3 515
47.2
3 311
62.2
Total
15 275
74.0
13 151
80.9
Impact of HIV/AIDS
on older persons
HIV/AIDS impacts older persons in two
ways:
Through infection: some older persons
are at risk of infection with the virus,
and some are already living with the
disease
Through caregiving: numerous older
persons care for orphaned and
vulnerable grandchildren (OVC)
Older persons marginalized
HIV is viewed as disease of the young
Older persons are viewed as being sexually
inactive
Their risk factors for infection are the same
as in the young
HIV/AIDS is frequently misdiagnosed
Older persons excluded from:
Educational programmes:
Sex education
Caregiver education
Disease burden and the
older population
Older persons are at increasing risk of
HIV infection
Progression to AIDS is rapid
Mortality is high due to:
Delayed diagnosis – infection not
suspected
Compromised immunity that occurs with
age
Presence of underlying chronic diseases,
poor nutrition
Impact on older persons
Affected (indirect impact)
National level
Reduced population of working adults
Competing for fewer public resources
Physical health
Carers of sick adult children and orphans
Caregiver stress and losses
Impact on their health
Cont.
Financial
Loss of traditional support structures
An increase in medical and living
expenses
Loss of wages
carer may have to
give up paying job
Psychosocial
Stigma: marginalized in their
communities
Lack of emotional support
Pain and sadness
Fear for the future
Grandmothers supporting sick and
disabled adult children and orphaned
children
Limited
resources
Lack of support
Stress
Depression
Exhaustion
Poor
health
and
increased
disability
Older people as agents of change
Older persons need basic HIV and AIDS
education
Knowledge in basic nursing and
parenting skills in a changing
environment
Increased access to HIV and AIDS
education will empower older persons to
protect themselves and those in their
care
Barriers to HIV/AIDS education
Majority of educators in HIV and AIDS
programmes are young people
Older people are reluctant to discuss their
sexuality, and personal factors affecting
them and their families with young
educators
Studies have shown that HIV and AIDS
knowledgeable and empowered older
women are effective leaders
Tlou 1996 & 1997
Research
Research is required to fully
understand the impact of
HIV/AIDS on older people and to
inform the development of
programmes to support them
Older persons’ contributions and needs
A Study to Understand and Foster the
Functioning and Involvement of Contributive
Elders (SUFFICE) is to be undertaken in Cape
Town from 2010
Will build on earlier phases of the SUFFICE
pre-pilot study, completed in 2007 (Ferreira et
al., 2007)
Pre-pilot study (n=55) compiled an inventory
of systematic descriptions of elders who make
substantial contributions to the well-being of
family and community
SUFFICE
Pre-pilot study demonstrated how:
Health limitations impinge on elders’ capacity to
contribute (more than three quarters reported a health
condition),
Proposed a health intervention to enhance their
functioning and thereby help to preserve their
contributive activities
Did not specifically assess knowledge and the
impact of HIV and AIDS in this population
The larger planned project will contribute to
development of a rationale to convince
stakeholders of the merits of a health and
education intervention for older people and a
need to include older people in national HIV and
AIDS programmes
SUFFICE 2010
SUFFICE remains a collaborative project of
institutions in Cape Town (South Africa) and New
York City (USA)
The Albertina and Walter Sisulu Institute of
Ageing in Africa at the University of Cape Town
and the Stroud Center for Study of Quality of life
at Columbia University in New York
An opportunity exists for those with common
interests to collaborate in the study
In an exploratory study conducted by the
Institute of Ageing in February 2010
(n=26), caregivers to HIV/AIDS children
and grandchildren reported they want
to:
Learn more about HIV and AIDS,
including medical, nutritional, financial,
social and care aspects
Specifically and interestingly, they want
information on:
What is CD4 count in layman’s terms
What is meant when CD4 count is low/high
What are ARVs exactly
How do ARVs work
What are the side effects of ARVs
How to learn about affordable nutritious diet
to prepare for PLWHA/OVC
How to protect oneself from being infected
during caring
Forward action plan
Urgent attention must be given to the growing risk
and incidence of infection in older persons through
screening, diagnosis and treatment
Policy must be formulated and implemented to
support older caregivers
Research is needed at the intersection of increasing
infection, and growing burden of care and its
impact on older persons
Older persons’ capacity and contributions in the
care management of the epidemic must be
sustained
University of Cape Town’s
Jameson Hall
Thank
you