A large, steadily growing HIV population in this country is living well into middle age and beyond, thanks to freely available treatment, but the challenges this presents were never predicted nor were they taken into consideration two decades ago, reports Business Day.
When Sibongile Tshabalala was diagnosed with HIV in 2000, then-President Thabo Mbeki’s Aids denialism was at its peak and activists were locked in battle with his administration over its refusal to provide life-saving treatment.
The focus was on survival. No one was thinking about what it might mean to grow old with HIV, says Tshabalala, now the chair of the Treatment Action Campaign (TAC).
But today, South Africa has a large and steadily growing HIV population: according to recent research in The Lancet, by 2040, more than half the of the HIV+ people in this country will be at least 50, up from just 30% in 2025.
“In the early 2000s the lifespan of people with HIV was about 35. But we have seen a big change with people accessing ARVs – and are now starting to see a lot of challenges we never anticipated,” says Tshabalala.
As people age, the likelihood of chronic conditions like diabetes, hypertension and cardiovascular disease increases. Those risks are heightened for people with HIV, says Linda-Gail Bekker, director of the Desmond Tutu HIV Foundation.
“HIV speeds up the metabolic clock, even if a person is on ARVs. It’s a double whammy: not only is the treatment pool getting older in absolute terms, but it is ageing relatively more quickly,” she says.
A host of conditions, ranging from diabetes to strokes, manifest at a younger age in people with HIV, says Stellenbosch University infectious disease specialist Jantjie Taljaard. Cancers are not only diagnosed earlier but are also often more aggressive and harder to treat because the immune system of an HIV+ person has diminished capacity to fend off disease – even if they’re taking antiretrovirals, he says.
Women, who bear the brunt of South Africa’s HIV/Aids epidemic, are especially vulnerable to the human papilloma virus (HPV).
Estimates of the scale of the risk vary: global research in The Lancet found HIV increased the likelihood of cervical cancer sixfold, while a South African study that examined claims data from half a million women, who belonged to a large medical scheme, and published in the International Journal of Cancer, found those with HIV had triple the risk of developing cervical cancer compared to women without HIV.
Cervical cancer was flagged by the WHO as the leading cause of cancer deaths among women in South Africa. The problem is well recognised, but as so often is the case with healthcare in South Africa, access to screening services hinges on socio-economic status.
Government guidelines say women with HIV should be offered cervical cancer screening when they are diagnosed and every three years after that. But provision in the overcrowded public health service is patchy and many women still get diagnosed only when the disease is advanced and harder to treat.
By contrast, women who can afford medical scheme membership are screened more frequently and consequently diagnosed earlier.
“Since 2018 we have allowed members to have annual pap smears (if they are HIV positive), as opposed to every three years,” says chief clinical officer at Discovery Health, Noluthando Nematswerani. The scheme also encourages people with HIV to get regular shots against flu and pneumococcal disease.
The numbers confronting South Africa are staggering: it has the world’s largest HIV population, with almost 8m people infected, of whom 6.3m are on treatment, according to the latest estimates from the Thembisa model. By 2040, the country’s HIV population aged 50 and above is set to reach 3.9m people, up from 2.3m in 2025, according to The Lancet.
While the government has been remarkably successful in expanding access to HIV treatment, its programmes were not created with an ageing population in mind. As a result, a person with HIV and multiple chronic diseases is expected to make separate visits to their local public clinic for each condition, often sacrificing the better part of a day to do so, says Tshabalala.
“We need an integration of services, so when I go to a clinic or hospital, I see one doctor who can look at everything. I should not be given different days to get my medicines,” says Tshabalala, who also has asthma.
The TAC is campaigning for Health Minister Aaron Motsoaledi to make good on his promise to supply stable HIV patients with six months’ worth of ARVs at a time. This would make it easier for people to maintain their treatment by cutting the their travel costs, and it would slash congestion in crowded facilities and lessen the load on overwhelmed nurses.
These same nurses will be expected to take on the job of caring for the incoming “silver tsunami” of ageing HIV patients, as South Africa has only a handful of geriatricians who specialise in the needs of older adults, says Wits infectious disease specialist Evan Shoul, who co-authored new clinical guidelines for older people with HIV, recently published in the Southern African Journal of HIV Medicine.
“The specialists dealing with this particular group are in very short supply because it’s not considered a particularly sexy or well remunerated discipline,” he says, noting that the problem is not unique to South Africa. Even in wealthier nations, there are too few geriatricians to meet the needs of an ageing population.
The guidelines propose task-shifting care for older adults with HIV from specialists to GPs and nurses, in much the same way that HIV treatment has been devolved and can now be prescribed by suitably trained nurses and pharmacists.
“Twenty years ago, HIV was a specialised condition that had to be managed by a specialist team. Over the years, HIV clinicians democratised that information, because the numbers were just so large,” says Shoul.
The guidelines recognise that the challenge has gone beyond helping people survive HIV to ensuring they age well. This means not only maintaining their physical health but also their mental well-being, independence and overall quality of life.
“Now we can shift to other aspects of care that might previously have been overlooked,” says Shoul, who says he’s seen a marked change among many of his older patients, who were diagnosed with HIV decades ago.
These days, instead of being anxious about their ARVs, which they take without fail, they are concerned about managing their risks of other illnesses. They ask for vaccines to protect themselves against illnesses like flu and pneumonia, and screening tests for cancer, he says.
David Abrahams is 80 and has been had HIV for more than three decades after a malicious stranger jabbed him with an infected needle in a nightclub one evening.
He never found out who the person was or why they launched the attack, and has been determined not to dwell on it. Thanks to his medical scheme cover, he had the means to obtain ARV treatment before it was widely available in the public sector. He says he now barely thinks twice about his daily pill, which he takes just before bed.
He still runs a furniture restoration business, regularly mountain bikes, and credits his well-being to luck, a positive attitude and a healthy lifestyle.
“Most people I knew 30 years ago have died. They did not look after themselves – they used to party and drink, smoke weed and do all sorts of things, which I don’t do at all,” he says.
See more from MedicalBrief archives:
Older HIV+ adults to overtake younger patients by 2040 – Lancet report
HIV among older South Africans neglected – Wits-Harvard study