Whereas 53.4% of all (both HIV-infected and uninfected) those aged 18–49 did not have any chronic condition, only 22.0% of those aged 50 and older did not. Only 8.8% of those aged 18–49 years had two or more conditions compared with 29.6% of those aged 50 and older (P < 0.0001).
Second analysis compares comorbidities among HIV-infected individuals aged 50 and older against HIV-infected individuals aged 18–49. Rates of hypertension among HIV-infected individuals were significantly higher (P = 0.0003) among those above the age of 50. WHODAS was higher among HIV-infected older adults (23.0) than among those HIV-infected individuals aged 18–49 (6.2) (P ≤ 0.0001).
After adjusting for age and sex using logistic regression, arthritis was the only chronic condition that was statistically significantly associated with HIV status among people aged 50 years and over (Table 3). Among individuals aged 50 years and older, living with HIV was associated with a lower prevalence of arthritis [odds ratio 0.30 (95% confidence intervals 0.14–0.65); P = 0.002]. Among those aged 50 and older, age and sex were not associated with the presence of chronic conditions. When including those aged 18–49 as well as older individuals, as expected, there was a significant positive association between older age and presence chronic conditions.
Among those 50 years of age and older, levels of happiness and life satisfaction were lower among those who were HIV-infected. When asked how satisfied they were with life as a whole, 51.8% of HIV-infected individuals responding ‘satisfied’ or ‘very satisfied’ compared with 60.6% of those HIV-uninfected (P = 0.039). When asked about their level of happiness, 34.6% of the HIV-infected respondents replied ‘happy’ or ‘very happy’ compared with 55.5% of those HIV-uninfected (P < 0.0001).
HIV prevalence among adults aged 50 and older in South Africa remains high and is particularly elevated among Africans, women aged 50–59 years, those living in rural areas and in some provinces such as Free State and KwaZulu-Natal. Rates of chronic disease were higher among all older adults compared with those aged 18–49 years. HIV status, however, was only statistically significantly associated with arthritis and not with any of the other conditions that we studied. When controlling for age and sex among those aged 50 and older, HIV status was significantly associated with lower BMI and weaker grip strength.
Our finding of 6.4% prevalence among all individuals aged 50 years and older is similar to that found by Peltzer et al.  in the 2005 South African HIV prevalence and behavioral survey (5.8%) and in the 2008 South African national HIV prevalence, incidence, behavior and communication survey (6.0%) . The higher rate of HIV prevalence among women aged 50–59 relative to men of the same age found in this study was not seen in those two studies. The 3.3% HIV prevalence rate among those aged 70 and older could cautiously be taken as evidence of old age incidence.
A Ugandan study using the same survey methodology also found significantly lower BMI among HIV-infected older people compared with HIV-uninfected counterparts as well as lower rates of hypertension . Overall, the Ugandan study found that older adults living with HIV had a similar health and functional status as other older people.
Despite significant evidence from developed country settings of associations between HIV and various chronic conditions, these were generally not found in this study among those aged 50 and older. Evidence of links between HIV and diabetes , cardiovascular disease , cerebrovascular and ischemic heart diseases , hypertension  and stroke  have been found in various studies in developed countries. HIV-associated arthritis has been observed in high-income countries linked to both HIV infection  and some antiretroviral medications  and emerging evidence from Uganda shows high rates of rheumatic manifestations among HIV-infected individuals , although the Ugandan study did not have a HIV-uninfected comparison group. Despite this, our findings reveal lower rates of arthritis among those living with HIV aged 50 and older. There are many types of arthritis with differing causes and there is evidence that some types of ART might reduce the frequency of some types of arthritis [38,39]. Further research is needed on the interaction between HIV, antiretroviral drugs and immune function in the occurrence and severity of various forms of arthritis.
The study is enhanced by the oversampling of older adults in SAGE providing a nationally representative perspective on the health of older adults. The approximately 25% missing HIV status values, however, may introduce bias, which could be leading to the lack of relationships observed between HIV status and various comorbidities in this study. Those with missing data were more likely to be female, African and slightly younger than those who responded. This might explain the high prevalence of HIV found in women aged 50–59 years in this study.
For a number of chronic conditions, prevalence was determined based on responses to a set of self-reported symptom questions rather than clinical diagnosis. This can lead to imprecision based on each individual's interpretation of the question – especially in cases of neurological or cognitive deficit. For measures such as hypertension based on blood pressure, the reporting of prevalence based on established cut-off points ignores the continuous association between blood pressure and hypertension .
The question of multimorbidity is critical to the future care and treatment models of HIV. There is a shift in care from a focus on opportunistic infections and AIDS-defining malignancies to a new set of chronic comorbidities, which may be due to chronic inflammation from long-term HIV infection as well as ART toxicities exacerbated by aging [13,17,43,44]. Evidence from developed countries shows high levels of multimorbidity among older adults [45,46]. A multimorbidity perspective has been recommended when considering optimal healthcare for older people, as it is more patient-centered and captures potentially interacting conditions .
This has important implications for integration of chronic care models in already strained developing country health systems. There is an opportunity to leverage the investment in HIV systems to develop an integrated response to a range of chronic diseases . Chronic disease clinics that provide continuity of care, long-term adherence support and can prevent and monitor drug interactions and reactions is needed to ensure a high level of care .
In addition to the chronic conditions, the weaker grip strength, lower BMI and higher disability score highlights poorer overall health among older adults living with HIV compared with older adults who do not have HIV. More attention is needed to poverty, nutrition and access to disability and health services among older adults with HIV.
South Africa has added men over 50 to its list of most at-risk populations, meriting extra attention in the national HIV response . Despite misperceptions to the contrary, older adults aged 50 and older in South Africa remain sexually active with 63% of men and 30% of women having had sex in the past month . The most recent sexual partner of more than 11% of men aged 50–59 was aged 31–40 years, suggesting that intergenerational relationships remain of concern to HIV transmission . National communication programs have failed to sufficiently target older adults leading to lower rates of HIV knowledge among those aged 50 and older [6,50].
Future research among older adults living with HIV in sub-Saharan Africa, including upcoming SAGE surveys, will need to take into account access to ART, time on ART and the amount of time that an individual has been HIV-infected in order to better assess prevalence and incidence of comorbidities. Further diagnostic tests for chronic conditions – in addition to self-reported symptomatic algorithms – would enhance precision. Cancer and dementia are additional important health challenges among older adults and among people living with HIV that should be included in future studies. Furthermore, efforts to integrate care should be evaluated for their impact on quality of care, outcomes and avoidance of adverse drug reactions. As the HIV epidemic in Africa ages, more evidence will be needed to end the neglect of older adults and develop models of care that meet the needs of this vulnerable group.
J.N. was partly funded by an Australian National Health and Medical Research Council capacity building grant. A.M. was in-part funded by an unrestricted educational Fellowship from Merck Inc. during the writing of this manuscript.
SAGE was carried out in partnership with the WHO, the South African Human Sciences Research Council (HSRC) and the South African National Department of Health (NDOH). Financial support for SAGE was provided by the NDOH, the United States National Institute on Aging's Division of Behavioral and Social Research, the HSRC and WHO.
There are no conflicts of interest.
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