Experts are raising the alarm yet again – and more so in the wake of the US funding cuts – regarding the alarming numbers of ageing South Africans with HIV, and their accompanying burdens of non-communicable diseases.
The proportion of older people with HIV has doubled over the past decade, and today, over-50s make up the second largest group of South Africa’s HIV-positive population. Just 20 years ago, they were the smallest proportion.
As people age, their chance for developing health problems like high blood pressure, heart disease and diabetes rises, meaning more and more people will have to be treated for these conditions, on top of getting HIV care.
However, without tracking the numbers – which will be challenging with the loss of thousands of US Government-funded data capturers in the wake of foreign aid cuts – putting plans in place to care for an ageing HIV population will be hard, writes Linda Pretorius for Bhekisisa, who looks at what South Africa’s data show, and what the country needs to prepare for.
The success of South Africa’s HIV treatment programme, the largest in the world, has also created a slumbering threat: a considerably larger group of people who need to be treated for age-related illnesses and non-communicable diseases.
Because ARVs increase life expectancy, the scale-up of treatment in South Africa means most people with HIV and who take ARVs correctly now live just as long as those without the virus.
Bhekisisa’s data analysis shows the proportion of older people with HIV has doubled over the past decade, and if this trend carries on, there could be three times as many HIV-positive people over 50 by 2030 as in 2015.
With nearly two-thirds of all people with HIV living in sub-Saharan Africa, the continent will continue bearing the brunt of the epidemic, despite massive gains in curbing new infections over the past 15 years – if health systems aren’t geared to handle a growing number of people who have both HIV and a chronic illness like heart disease or diabetes.
Experts had already raised the alarm about this “inevitable price of success” more than a decade ago.
Yet, write the authors of an editorial in a March issue of The Lancet Healthy Longevity, without thorough data on older people with HIV in African countries, putting plans for their healthcare in place will be hard, or not be done at all.
And with many governments, including South Africa’s, scrambling to find the money to replace the thousands of data capturers for HIV programmes previously funded by the US, funding for tracking health conditions of older people with HIV is likely to be a low priority.
As people age, their chance for developing health problems like high blood pressure, heart disease and diabetes rises, meaning people with HIV might live long lives, but not necessarily healthy ones.
In the wake of funding cuts, employing health workers to capture and manage health data will be a hard sell, said Kate Rees, a public health specialist with the Anova Health Institute, during a webinar hosted by Bhekisisa and the Southern African HIV Clinicians Society last week, and which could make the problem much worse.
What then, does South Africa’s picture look like, and could policymakers stave off a calamity in the making?
Here’s what the numbers show.
The proportion of people with HIV and who are 50 or older is growing – and faster than increases in other age groups.
In 2015, the count in the 50+ age group was just more than 700 000, which translates to about 12% of the total HIV-positive population. The age group 40-49 years, though, was about 1.3m strong, which works out to 22% of the total.
A decade later, the 50-pluses’ total had jumped by 1.15m to reach 1.85m, and they now make up roughly 24% of the total number of HIV-positive South Africans.
Although the 40-49 group’s total also grew by 1.15m, proportionally they now make up 32% of everyone.
In other words, the proportion of older people with HIV doubled in a decade, but the proportion of people 10 years younger grew only 1.5 times bigger – a result, experts say, of people with HIV living longer, new infections still happening in older people, and fewer new cases in the younger group. If this trend carries on, there could be three times as many HIV-positive people over 50 by 2030 as in 2015.
Speeding up, changing ranks
People over 50 are the second biggest HIV-positive group in South Africa today. Fifteen years ago, they were the smallest group.
Around 2012, the 50-plusers moved up one rank, surpassing growth in the under-20s group. But the number of HIV-positive people between 35 and 49 grew rapidly, and by around 2012 they overtook the group aged 20–34 and assumed top rank.
In the following years, the 50+ group increased too: people moved out of their late 40s and new infections in that age group continued. By 2026, about 10 years since their previous rank jump, over-50s will already have been the second biggest group of the HIV-positive population for some time.
The 35-49-year group will keep on growing in the next five years, modelled data shows, albeit more slowly than before. Because people are living longer, the older group will grow too as people move into their 50s, and because it’s been expanding for some time already, the group will edge closer and closer to top rank over the coming years.
Living long, but not necessarily healthy
This is where the warning lies. Data from 2020 show that, when Covid-19 is ignored, one in seven deaths in people between 45 and 64 were due to health problems like heart attacks, stroke and high blood pressure that year. In comparison, only one in 20 deaths in that age group were linked directly to HIV.
Above 65, a quarter of deaths were from these conditions. In fact, there were so few linked to HIV in this age group that, proportionally, it was hardly a noticeable concern.
So, as the peak of the HIV-infected population shifts into an older age band, more and more people will probably have to be treated for non-communicable diseases like heart conditions, diabetes, overweight and high blood pressure, on top of receiving HIV care.
In fact, in a large study in Mpumalanga, in which most people were in their late 40s to early 70s, about half had at least two age-related illnesses.
For example, in this sample of just more 5 000 people, six in 10 had high blood pressure, with it being more likely the older someone was. About 10% of women had angina and up to 11% of people had high cholesterol.
High blood pressure combined with high cholesterol can damage the arteries, and ups the chances for fatty plaques building up along the walls of the blood vessels. This narrows and stiffens the arteries, meaning blood pressure builds up even more and the chance of a blood vessel rupturing increases.
High blood pressure can lead to angina or a heart attack because the heart muscle gets too little oxygen, and also cause a suite of other health problems – or metabolic syndrome, which includes conditions like diabetes, stroke and heart disease.
Age-related health problems like heart disease, diabetes and overweight are often linked to inflammation, but it’s even more common with HIV-infection. Studies have shown that over-50s with HIV have double the chance of having conditions like diabetes or high blood pressure than younger HIV-positive people.
“In future, every clinic nurse will have to be Nimart trained,” said Ndiviwe Mphothulo, president of the Southern African HIV Clinicians Society at last week’s webinar.
Nimart nurses (short for Nurse-Initiated Management of Antiretroviral Treatment) are specially trained in how to prescribe ARVs and manage long-term patients.
But, experts say, the flip side is also true if South Africa is to deal with the ageing HIV epidemic: every Nimart nurse will have to be equipped to deal with non-communicable diseases in this population too.
See more from MedicalBrief archives:
HIV among older South Africans neglected – Wits-Harvard study
Fewer South Africans dying of HIV, but infection numbers rising
Survey shows HIV rates soaring in Mpumalanga
Almost 40% of the world’s anti-HIV pill users live in South Africa
One in four HIV+ South Africans not on treatment