Joel Negin

HIV infection in older adults in sub-Saharan Africa: extrapolating prevalence from existing data.

OBJECTIVE To quantify the number of cases and prevalence of human immunodeficiency virus (HIV) infection among older adults in sub-Saharan Africa. METHODS We reviewed data from Demographic and Health Surveys (DHS). Although in these surveys all female respondents are < 50 years of age, 18 of the surveys contained data on HIV infection among men aged ≥ 50 years. To estimate the percentage of older adults (i.e. people ≥ 50 years of age) who were positive for HIV (HIV+), we extrapolated from data from the Joint United Nations Programme on HIV/AIDS on the estimated number of people living with HIV and on HIV infection prevalence among adults aged 15-49 years. FINDINGS In 2007, approximately 3 million people aged ≥ 50 years were living with HIV in sub-Saharan Africa. The prevalence of HIV infection in this group was 4.0%, compared with 5.0% among those aged 15-49 years. Of the approximately 21 million people in sub-Saharan Africa aged ≥ 15 years that were HIV+, 14.3% were ≥ 50 years old. CONCLUSION To better reflect the longer survival of people living with HIV and the ageing of the HIV+ population, indicators of the prevalence of HIV infection should be expanded to include people > 49 years of age. Little is known about comorbidity and sexual behaviour among HIV+ older adults or about the biological and cultural factors that increase the risk of transmission. HIV services need to be better targeted to respond to the growing needs of older adults living with HIV.

Feasibility, acceptability and cost of home-based HIV testing in rural Kenya

Objective  To demonstrate the feasibility, acceptability and cost of home‐based HIV testing and to examine the applicability of the model to high HIV prevalence settings.

Brain Gains: a literature review of medical missions to low and middle-income countries.

BackgroundHealthcare professionals’ participation in short-term medical missions to low and middle income countries (LMIC) to provide healthcare has become common over the past 50 years yet little is known about the quantity and quality of these missions. The aim of this study was to review medical mission publications over 25 years to better understand missions and their potential impact on health systems in LMICs.MethodsA literature review was conducted by searching Medline for articles published from 1985–2009 about medical missions to LMICs, revealing 2512 publications. Exclusion criteria such as receiving country and mission length were applied, leaving 230 relevant articles. A data extraction sheet was used to collect information, including sending/receiving countries and funding source.ResultsThe majority of articles were descriptive and lacked contextual or theoretical analysis. Most missions were short-term (1 day – 1 month). The most common sending countries were the U.S. and Canada. The top destination country was Honduras, while regionally Africa received the highest number of missions. Health care professionals typically responded to presenting health needs, ranging from primary care to surgical relief. Cleft lip/palate surgeries were the next most common type of care provided.ConclusionsBased on the articles reviewed, there is significant scope for improvement in mission planning, monitoring and evaluation as well as global and/or national policies regarding foreign medical missions. To promote optimum performance by mission staff, training in such areas as cross-cultural communication and contextual realities of mission sites should be provided. With the large number of missions conducted worldwide, efforts to ensure efficacy, harmonisation with existing government programming and transparency are needed.

HIV and Aging — Preparing for the Challenges Ahead

By 2015, half of HIV-infected U.S. patients will be older than 50 years of age. As antiretroviral therapy coverage expands globally, the aging of the epidemic will be mirrored in developing countries. Yet the world is unprepared to deal with an aging population with HIV.

Male sex and the risk of mortality among individuals enrolled in antiretroviral therapy programs in Africa: A systematic review and meta-analysis

Background:HIV/AIDS has historically had a sex and gender-focused approach to prevention and care. Some evidence suggests that HIV-positive men have worse treatment outcomes than their women counterparts in Africa. Methods:We conducted a systematic review and meta-analysis of the effect of sex on the risk of death among participants enrolled in antiretroviral therapy (ART) programs in Africa since the rapid scale-up of ART. We included all cohort studies evaluating the effect of sex (male, female) on the risk of death among participants enrolled in regional and national ART programs in Africa. We identified these studies by searching MedLine, EMBASE, and Cochrane CENTRAL. We used a DerSimonian-Laird random-effects method to pool the proportions of men receiving ART and the hazard ratios for death by sex. Results:Twenty-three cohort studies, including 216 008 participants (79 892 men) contributed to our analysis. The pooled proportion of men receiving ART was 35% [95% confidence interval (CI): 33–38%]. The pooled hazard ratio estimate indicated a significant increase in the risk of death for men when compared to women [hazard ratio: 1.37 (95% CI: 1.28–1.47)]. This was consistent across sensitivity analyses. Interpretation:The proportion of men enrolled in ART programs in Africa is lower than women. Additionally, there is an increased risk of death for men enrolled in ART programs. Solutions that aid in reducing these sex inequities are needed.

Integrating a broader notion of food security and gender empowerment into the African Green Revolution

A Green Revolution for Africa is emerging after decades of neglect of Africa’s agricultural systems. To counter these years of neglect, the then United Nations Secretary-General Kofi Annan called for “a uniquely African Green Revolution”. Since then, a number of initiatives have emerged or are emerging to realize this important vision. As more money and attention galvanizes much-needed action on the African Green Revolution, a vigorous debate is required to ensure that the mission of improving food security on the world’s poorest continent is achieved in the most effective, comprehensive and inclusive manner possible. The African Green Revolution cannot be limited to increasing yields of staple crops but must be designed as a driver of sustainable development, which includes gender empowerment and nutrition elements. This paper first reviews the Asian Green Revolution’s successes and shortcomings from a nutrition and gender perspective and then outlines what the global community can do to ensure that some of the limitations of the Asian Green Revolution, specifically with regard to nutrition and gender, are not repeated.

Prevalence of HIV and chronic comorbidities among older adults

Objectives:Limited evidence is available on HIV, aging and comorbidities in sub-Saharan Africa. This article describes the prevalence of HIV and chronic comorbidities among those aged 50 years and older in South Africa using nationally representative data. Design:The WHOs Study of global AGEing and adult health (SAGE) was conducted in South Africa in 2007–2008. SAGE includes nationally representative cohorts of persons aged 50 years and older, with comparison samples of those aged 18–49 years, which aims to study health and its determinants. Methods:Logistic and linear regression models were applied to data from respondents aged 50 years and older to determine associations between age, sex and HIV status and various outcome variables including prevalence of seven chronic conditions. Results:HIV prevalence among adults aged 50 and older in South Africa was 6.4% and was particularly elevated among Africans, women aged 50–59 and those living in rural areas. Rates of chronic disease were higher among all older adults compared with those aged 18–49. Of those aged 50 years and older, 29.6% had two or more of the seven chronic conditions compared with 8.8% of those aged 18–49 years (P < 0.0001). When controlling for age and sex among those aged 50 and older, BMI was lower among HIV-infected older adults aged 50 and older (27.5 kg/m2) than in HIV-uninfected individuals of the same age (30.6) (P < 0.0001). Grip strength among HIV-infected older adults was significantly (P=0.004) weaker than among similarly-aged HIV-uninfected individuals. Conclusion:HIV-infected older adults in South Africa have high rates of chronic disease and weakness. Studies are required to examine HIV diagnostics and treatment instigation rates among older adults to ensure equity of access to quality care, as the number and percentage of older adults living with HIV is likely to increase.

Aging with HIV in Africa: the challenges of living longer.

The global response to the HIV epidemic and the successful scale-up of antiretroviral therapy (ART) represents one of the greatest public health achievements of this century. The HIV response was initially defined by a focus on mothers and children and as treatment expanded and resources increased globally new groups received particular attention including sex workers drug users and migrants. One group that has so far received little attention in the HIV response in developing countries has been older adults. Several opportunities to highlight the emerging trend of the aging of the HIV epidemic and the potential impact of this trend on the HIV response has been missed. Aids2031 the group established by UNAIDS to chart the actions needed to address the trajectory of the HIV epidemic over the coming decades has emphasized the need for a shift in the response from ‘crisis management to sustained strategic response.’ However the group does not discuss the substantial changes to the HIV response that will likely become necessary as the large-scale delivery of ART will change the age composition of HIV-infected populations over the coming decades. The findings discussed in this article show that the current neglect of the elderly in HIV prevention efforts is unwarranted and that HIV prevention interventions targeted at the specific needs of older adults are needed.

Task-shifting and prioritization: a situational analysis examining the role and experiences of community health workers in Malawi

BackgroundAs low- and middle-income countries face continued shortages of human resources for health and the double burden of infectious and chronic diseases, there is renewed international interest in the potential for community health workers to assume a growing role in strengthening health systems. A growing list of tasks, some of them complex, is being shifted to community health workers’ job descriptions. Health Surveillance Assistants (HSAs) - as the community health worker cadre in Malawi is known - play a vital role in providing essential health services and connecting the community with the formal health care sector. The objective of this study was to understand the performed versus documented roles of the HSAs, to examine how tasks were prioritized, and to understand HSAs’ perspectives on their roles and responsibilities.MethodsA situational analysis of the HSA cadre and its contribution to the delivery of health services in Zomba district, Malawi was conducted. Focus groups and interviews were conducted with 70 HSAs. Observations of three HSAs performing duties and work diaries from five HSAs were collected. Lastly, six policy-maker and seven HSA supervisor interviews and a document review were used to further understand the cadre’s role and to triangulate collected data.ResultsHSAs performed a variety of tasks in addition to those outlined in the job description resulting in issues of overloading, specialization and competing demands existing in the context of task-shifting and prioritization. Not all HSAs were resistant to the expansion of their role despite role confusion and HSAs feeling they lacked adequate training, remuneration and supervision. HSAs also said that increasing workload was making completing their primary duties challenging. Considerations for policy-makers include the division of roles of HSAs in prevention versus curative care; community versus centre-based activities; and the potential specialization of HSAs.ConclusionThis study provides insights into HSAs’ perceptions of their work, their expanding role and their willingness to change the scope of their practice. There are clear decision points for policy-makers regarding future direction in policy and planning in order to maximize the cadre’s effectiveness in addressing the country’s health priorities.

High rates of AIDS-related mortality among older adults in rural Kenya.

Background:Health challenges faced by older people in developing countries are often neglected amidst a wide range of competing priorities. This is evident in the HIV field where the upper age limit for reporting HIV prevalence remains 49 years. However, the long latency period for HIV infection, and the fact that older people continue to be sexually active, suggests that HIV and AIDS are likely to affect older people. To better understand this, we studied mortality due to AIDS in people aged 50 and older in an area of rural Kenya with high rates of HIV infection. Methods:A community health worker-administered verbal autopsy system was introduced in Nyanza Province, encompassing 63,500 people. Algorithms were used to determine cause of death. Results:A total of 1228 deaths were recorded during the study period; 368 deaths occurred in people aged 50 years and older. AIDS was the single most common cause of death, causing 27% of all deaths. AIDS continued to be the main cause of death up to age 70 years, causing 34% of deaths in people aged 50-59 years and 23% of deaths in people aged 60-69 years. Conclusions:AIDS remains the principle cause of death among older people in Nyanza Province in western Kenya up until the age of 70 years. Greater efforts are needed to integrate older people into the HIV response and to better understand the specific vulnerabilities and challenges faced by this group.