This study employed a vital events and verbal autopsy system to examine patterns of mortality in rural western Kenya, with a particular focus on older adults. Communicable diseases were the most frequent cause of death with AIDS, malaria, respiratory infections, and diarrheal diseases causing the largest number of deaths. Among those aged 50 and older, AIDS remained the most significant cause of death up to the age of 70. It was only among those aged older than 70 that noncommunicable diseases surpassed AIDS as the most common cause of death.
Total annual mortality rates in this study were slightly lower than that seen across demographic surveillance systems sites in Tanzania, Ethiopia, Ghana, Burkina Faso, and Mozambique.36 In a study conducted in another area in Western Kenya in 2003, rates of cardiovascular disease, diarrheal disease, and respiratory infections rates were relatively similar to the rates found in our study, but rates of AIDS and tuberculosis mortality were higher and number of deaths through injuries was lower.37 Other studies have confirmed high rates of malaria mortality among older adults even in highly endemic areas where acquired immunity has been assumed.38-40
The high level of mortality found in this study suggests that AIDS is a very important cause of death among people older than 50 in rural Kenya. The HIV epidemic in Kenya is generalized and mature. Women are generally infected younger than men41 perhaps contributing to the higher rates of AIDS-related mortality among males older than 50 given the median 10-year period between infection and death.42 Recent studies in Kenya have estimated that, nationally, 5% of those infected with HIV are aged 50 years and older and that HIV prevalence is 7.8% among 50-year to 54-year olds, 3.6% among 55-59, and 2.7% among 60-year to 64-year olds.43 A home-based voluntary counseling and testing program in the project site revealed HIV prevalence of 6.8% among those aged 50 and older (8.5% in males, 5.8% in females).44 Prevalence among 50-year to 59-year olds was 10.0% (11.1% in males, 9.5% in females) and for those 60 and older, it was 4.8% (7.2% in males, 3.1% in females).
In one of the few sub-Saharan African studies to look carefully at causes of death in people 50 years and older, Adjuik et al38 found that, in Southern Africa, the AIDS mortality rate was higher in 45-year to 59-year olds than among 15-year to 44-year olds. Zaba et al,45 using cohort study data from 6 African sites, also show that mortality of HIV-infected persons increases steadily with age though their data stops at age 55 for some sites and 65 for others. This suggests that the results of this study are generalizable to locations beyond rural Kenya that share similar HIV prevalence rates.
Most studies on HIV and older adults in developing countries focus on the impact of HIV on economic and social roles-and in particular on the role of grandparents in caring for HIV orphans-with little regard to the prevalence of HIV in older people or the direct impact of HIV infection on their health.9,46,47 Misconceptions remain common regarding older people and HIV. The authors of a study in Nigeria assert that “older people are no longer sexually active, and it is believed that HIV/AIDS is not a major problem in that segment of the population.”48 This low sense of risk can potentially lead to older people not being tested as part of routine testing and low uptake of HIV counseling, testing, and other services. Kyobutungi et al10 lament the lack of HIV programs targeting older people in sub-Saharan Africa.
Reasons have been posited for the high rates of AIDS mortality among older people. The Collaborative Group on AIDS Incubation and HIV Survival has noted that the older the individual, the faster the progression from HIV infection to AIDS with life expectancy of only 4 years for those infected at age 65 or older.49 The high levels of HIV prevalence among older people might be related to remarriage after widowhood or divorce and the risk of forming HIV discordant partnerships.50 In general, however, the sexual activity of older individuals in the developing world is barely researched.9
Older populations also experience high rates of mortality due to noncommunicable diseases such as cardiovascular disease and diabetes. As has been reported elsewhere, such diseases are common even in rural areas of developing countries.51,52 However, the mortality rates from cardiovascular disease and diabetes in rural Kenya appear to be much lower than in rural India.53
CHW-administered VAs could potentially overlook a proportion of deaths, thus underrepresenting mortality. To assess this systematically, a 3-month retrospective review of all households was conducted. It revealed only one missing death during the assessment period suggesting information on the vast majority of deaths in the cluster are routinely captured using the CHW-based approach.
Over the past several decades, VAs have been increasingly accepted as a tool to assess mortality, and have undergone substantial methodological refinement. Although VAs have been validated in numerous studies,25-31 limitations include recall bias, alongside errors in classification, and verification.54,55 Additionally, many deaths are multifactorial with significant overlap between causes of death such as AIDS and tuberculosis. Multiple studies have, however, demonstrated a high correlation between VA cause of death and HIV status56,57 though the validity of VA in identifying child HIV deaths58 and older adult HIV death59 has been questioned. Another potential limitation is that, in rural populations in resource-poor countries, age reporting may be inaccurate especially among older age groups.18
With HIV and noncommunicable diseases together contributing to more than half of the deaths among older people in western Kenya, greater efforts are needed to address premature deaths arising from these conditions. Although responses have traditionally been implemented separately, there is increasing realization that there are significant synergies available. In particular, the shared “chronicity” of therapies for HIV, diabetes, and cardiovascular disease suggest that a unified response might be appropriate.60 HIV, cardiovascular disease, and diabetes are largely asymptomatic and require long-term treatments to prolong life, and therefore require similar systems of protocol-based decentralized delivery, with well-coordinated care and support to optimize adherence. Furthermore, the diseases themselves are biologically linked, as antiretroviral therapy has been associated with increased risk of diabetes61,62 and heart disease.63,64
The HIV treatment systems that have been developed in many African countries-adherence support, ongoing treatment delivery mechanisms, drug procurement procedures-could be leveraged to deliver noncommunicable disease programs. Already systems that had been developed for other diseases are shifting to respond to noncommunicable diseases; in Cambodia, for example, those trained to provide leprosy care are being retrained to support diabetes patients with foot care (Sally Duke, MBBS, MIPH, personal communication, August 2009).
The high rate of AIDS mortality among older adults highlights the need for targeted prevention and treatment efforts and research to develop a better understanding of the specific vulnerabilities facing this age group. As more individuals with HIV survive and as population aging continues, the challenge of HIV and older adults will only become more pressing.
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