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Antiretroviral therapy coverage associated with increased co-residence between older and working-age adults in Africa

De Neve, Jan-Waltera,b; Karlsson, Omarc,d; Coetzee, Lelanie,f; Schröder, Henninga,g; Subramanian, S.V.h,i; Bärnighausen, Tilla,b,j; Vollmer, Sebastianb,k

doi: 10.1097/QAD.0000000000001917
Epidemiology and Social
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Objectives: To determine whether national antiretroviral therapy (ART) coverage is associated with changes in the living arrangements of older adults.

Design: Retrospective analysis using 103 nationally representative surveys from 28 African countries between 1991 and 2015.

Methods: The sample consisted of individuals aged at least 60 years. We investigated how three measures of living arrangements of older adults have changed with ART coverage: the number of older individuals living without working-age adults, the number of older individuals living with only dependent children (i.e. ‘missing generation’ households), and the number of working-age adults per household where an older individual lives.

Results: Our sample consisted of 297 331 older adults. An increase in ART coverage of 1% was associated with a 0.7 percentage point reduction (P < 0.001) in the probability of an older adult living without working-age adult and a 0.2 percentage point reduction (P = 0.005) in the probability of an older adult living in a ‘missing generation’ household. Increases in ART coverage were also associated with more working-age adults in households with at least one older adult. In our study countries, representing 75% (749 million) of the sub-Saharan population, an additional 103 000–358 000 older adults could be living with working-age adults as a result of increased ART coverage (1%).

Conclusion: The scale-up of ART has likely led to substantial increases in co-residence between older and working-age adults in Africa. Returns to investments in HIV treatment will be too low, if the social benefits from these changes in living arrangements of older adults are not taken into account.

aInstitute of Public Health, Heidelberg University, Im Neuenheimer Feld 130.3, Heidelberg, Germany

bDepartment of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA

cCentre for Economic Demography

dDepartment of Economic History, Lund University, Lund, Sweden

eDepartment of Economics, University of Göttingen, Waldweg, Göttingen, Germany

fDepartment of Economics, University of Pretoria, Hatfield, South Africa

gFaculty of Medicine, University of Cologne, Albertus Magnus Platz, Cologne, Germany

hDepartment of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston

iCenter for Population and Development Studies, Harvard T.H. Chan School of Public Health, Cambridge, Massachusetts, USA

jAfrica Health Research Institute, Mtubatuba, KwaZulu-Natal, South Africa

kCenter for Modern Indian Studies, University of Göttingen, Waldweg, Göttingen, Germany.

Correspondence to Jan-Walter De Neve, MD, ScD, MPH, Institute of Public Health, Heidelberg University, Im Neuenheimer Feld 130.3, R.314, 69120 Heidelberg, Germany. Tel: +49 6221 5632873; e-mail: janwalter.deneve@uni-heidelberg.de

Received 21 January, 2018

Revised 20 May, 2018

Accepted 24 May, 2018

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Copyright © 2018 Wolters Kluwer Health, Inc.