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The impact of antiretroviral treatment on the age composition of the HIV epidemic in sub-Saharan Africa

Hontelez, Jan A.C.a,b,c; de Vlas, Sake J.a; Baltussen, Robb; Newell, Marie-Louisec; Bakker, Roela; Tanser, Frankc; Lurie, Markd; Bärnighausen, Tillc,e

doi: 10.1097/QAD.0b013e3283558526
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Introduction: Antiretroviral treatment (ART) coverage is rapidly expanding in sub-Saharan Africa (SSA). Based on the effect of ART on survival of HIV-infected people and HIV transmission, the age composition of the HIV epidemic in the region is expected to change in the coming decades. We quantify the change in the age composition of HIV-infected people in all countries in SSA.

Methods: We used STDSIM, a stochastic microsimulation model, and developed an approach to represent HIV prevalence and treatment coverage in 43 countries in SSA, using publicly available data. We predict future trends in HIV prevalence and total number of HIV-infected people aged 15–49 years and 50 years or older for different ART coverage levels.

Results: We show that, if treatment coverage continues to increase at present rates, the total number of HIV-infected people aged 50 years or older will nearly triple over the coming years: from 3.1 million in 2011 to 9.1 million in 2040, dramatically changing the age composition of the HIV epidemic in SSA. In 2011, about one in seven HIV-infected people was aged 50 years or older; in 2040, this ratio will be larger than one in four.

Conclusion: The HIV epidemic in SSA is rapidly ageing, implying changing needs and demands in many social sectors, including health, social care, and old-age pension systems. Health policymakers need to anticipate the impact of the changing HIV age composition in their planning for future capacity in these systems.

aDepartment of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands

bDepartment of Primary and Community Care, Nijmegen International Center for Health System Analysis and Education, Radboud University Nijmegen Medical Centre, The Netherlands

cAfrica Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, KwaZulu-Natal, South Africa

dDepartment of Epidemiology and the International Health Institute, Warren Alpert Medical School, Brown University, Providence, Rhode Island

eDepartment of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts, USA.

Correspondence to Jan A.C. Hontelez, Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands. Tel: +31 30 704 46 32; e-mail:

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Received 9 November, 2011

Accepted 1 May, 2012

© 2012 Lippincott Williams & Wilkins, Inc.