Unravelling the complexities of HIV care among HIV-positive older adults in Sub-Saharan Africa: The Case of Botswana

As the HIV epidemic ages, health systems globally are faced with the reality that infected persons whom, at the height of the epidemic and pre-ART, were not expected to live long now have to negotiate aging with HIV and associated complications. With increasing success in treating HIV, people are living well into later life with HIV, the bulk of which are in the developing world, particularly the sub-Saharan Africa (SSA) region. Although there has been some interest in this topic, policies and interventions have not been forthcoming. HIV as it relates to older adults specifically remains largely ignored in this region. A new challenge to thoroughly understand how the longevity of living with HIV is experienced within these resource limited settings has emerged. By identifying the epidemiology and characteristics of older adults living with HIV (chapter 1), gauging the experiences and effects of aging on PLWH (chapter 2), elucidating and understanding the scope of co-morbidities associated with aging (chapter 3), and examining the policies and systems (chapter 4) that are in place in the Botswana health sector to facilitate provision of health services to the aging population in light of HIV as well as other conditions associated with the natural process of aging, this thesis aims to examine the quality of life, availability and effectiveness of care, as well as explore the experiences of older adults living with HIV. Botswana is a country in sub-Saharan Africa which besides being known to have the second highest documented national HIV prevalence (18.5%) in world, has been one of the very few in the region that has created a successful HIV treatment program. In addition to the introduction and conclusions, this thesis contains four distinct, yet related chapters derived from related research work either published or under review in accordance with the requirements of the University of Sydney thesis by Publication Format. The introduction provides a general overview and background summary of the literature on HIV and aging, the effects of these disease on adults globally, literature on older adults living with HIV as it relates to SSA, and Botswana in particular. Chapter one uses national AIDS impact surveys to highlight the epidemiology and characteristics of older adults who are on HIV treatment and their treatment outcomes. It details demographic analyses of older people living with HIV in Botswana. Chapter two examines the implications of the increase in the number of older PLWH on the health and social systems needed to provide adequate care and treatment. It looks in to the psychological effects of aging with HIV, life of poverty, secrecy, lack of social support and associated stigma, co-morbidity, the stress of aging associated with older PLWH’s unique circumstances, and coping strategies in Botswana. Chapter three gauges the impact and effects of HIV and chronic illnesses on older PLWH on treatment, paying particular attention to the scope of co-morbidities associated with aging phenomenon. Chapter four examines the policies that are in place or lack thereof, in the Botswana Health sector, to facilitate provision of health care services to cope with an aging population. Together these chapters provide a synergistic exploration of the issue of aging and HIV in a highly affected and resource challenged setting. The complex relationship of antiretroviral therapy, HIV and age, the implications of the increase in the number of older people living with HIV, on the health and social systems with the development and treatment of comorbidities makes the comprehensive care of older HIV infected patients a challenging endeavour