"I am adhering to HIV treatment so that I can live to support her": A qualitative study of upward intergenerational support in South Africa.

Background: Intergenerational family care, which was upended by the HIV epidemic in sub-Saharan Africa (SSA), may return to a pre-HIV era arrangement as access to antiretroviral therapy (ART) expands and treated adults can once again provide support for older household members. Empirical research has demonstrated positive 'spillover effects' of ART uptake from treated adults to younger generations, yet much less is known about the nature and breadth of such effects to older generations. This study explores the role and lived experiences among adults who take up ART and those of an older generation with whom they live. Methods: We conducted a qualitative study consisting of semi-structured interviews (n = 46) embedded in the Agincourt Health and Demographic Surveillance System (HDSS) in rural South Africa, between July and September 2022. We purposefully sampled two respondent categories: (i) young or middle-aged adults on ART (aged 18-59 years old); and (ii) older adults (aged ≥60 years old) who were affiliated with a young or middle-aged adult on ART. We used thematic content analysis to extract, code, and categorise relevant text by types of upward spillover effects from ART in younger adults to older adults. Quantitative data was extracted from the existing Agincourt HDSS database and matched to qualitative interview data based on Clinic link unique identifiers of study participants. Results: Mean age was 41 years among young or middle-aged adults (n = 29) and 72 years among older adults (n = 17). Among younger adults, time on ART ranged from five months to more than 21 years. Both young or middle-aged adults on ART and older adults reported positive spillover effects for older adults across five main tiers: caregiving, financial support, physical and mental health, living arrangements and household relationships, and stigma and reputation. Spillover challenges included financial costs and caregiving responsibilities following ART initiation of young or middle-aged adults, although these additional caregiving responsibilities were generally not perceived as particularly burdensome. Conclusions: ART is likely to benefit older adults in South Africa whose families are affected by HIV. This study identified a wide range of perceived spillover effects from ART in younger adults to older adults, including improvements to upward intergenerational support. These qualitative findings offer a guide to researchers, policymakers, and donors to capitalise on the broader societal effects of a large-scale health intervention to further support family structures and meet the needs of a growing older population.

Development of a Tablet Computer Application for HIV Testing and Risk History Calendar for Use With Older Africans.

Life history calendars (LHCs) are able to capture large-scale retrospective quantitative data, which can be utilized to learn about transitions of behavior change over time. The Testing and Risk History Calendar (TRHC) is a version of life history calendar (LHC) which correlates critical social, sexual and health variables with the timing of HIV testing. In order to fulfill the need for time-bound data regarding HIV testing and risk of older persons in South Africa, a pilot of the TRHC was performed using a paper fold-out grid format. Though the TRHC study in this format was effective as older persons were able to recall details about their HIV testing and risk contexts, the interview process was tedious as data were collected manually. Development of a tablet application for TRHC study will improve data quality and make data entry and collection more automated. This paper presents the development of the TRHC application prototype in order to collect TRHC data electronically and provides a platform for efficient large-scale life history calendar data collection.

Social engagement and survival in people aged 50 years and over living with HIV and without HIV in Uganda: a prospective cohort study.

This study examined the association between social engagement and survival in people with or without HIV aged 50 years and over in Uganda. We analysed two waves of a survey from two sites in Uganda to assess predictors of mortality between waves. The first wave was conducted between 2009 and 2010 while the second wave was conducted between 2012 and 2013. A standardised questionnaire adapted from the World Health Organization study on global AGEing and adult health (SAGE) was administered through face-to-face interviews at both survey waves. Cox proportional hazards models and Nelson-Aalen cumulative hazards functions were used to investigate associations between the strength of participants' social ties, using distance and intimacy metrics, and their social engagement with mortality between waves. Of the original 510 participants, 63 (12.3%) died between waves. Being more socially engaged and able to provide in-kind or financial contributions to family or friends were protective. After adjusting for covariates neither social tie measure was predictive of mortality. There were no significant differences in social engagement and survival by HIV status. Further research is needed in African settings on the relationship between social relationships and subsequent mortality in older adults to assess if improved social relationships could moderate mortality.

Timing of Most Recent Health Care Visit by Older People Living With and Without HIV.

The objective of this article is to document factors associated with the recency of health-care service utilization by people aged 50 years and over living with and without HIV in Uganda. A survey was conducted with 510 Ugandans aged 50 and older, living with and without HIV. The survey included information on sociodemographic characteristics, health state, self-reported chronic conditions, and timing of most recent visit to a health-care facility (time since last visit [TSLV]). We use ordinal logistic regression to identify independent factors associated TSLV. Independent factors associated with TSLV (>6 months) include age, OR = 2.40 [95% CI 1.08-5.37] for those aged 80 years and above, urban respondents, OR = 0.6 [95%CI 0.38-0.94], HIV-positive respondents, OR = 0.33 [95%CI 0.18-0.59], and better health. To understand the meaning of these finding, further investigation should examine (a) how best to define and measure older persons' health-care service needs and (b) older persons' decision-making processes around the timing of their access to health-care facilities.

Chronic disease, risk factors and disability in adults aged 50 and above living with and without HIV: findings from the Wellbeing of Older People Study in Uganda.

BACKGROUND: Data on the prevalence of chronic conditions, their risk factors, and their associations with disability in older people living with and without HIV are scarce in sub-Saharan Africa. OBJECTIVES: In older people living with and without HIV in sub-Saharan Africa: 1) to describe the prevalence of chronic conditions and their risk factors and 2) to draw attention to associations between chronic conditions and disability. METHODS: Cross-sectional individual-level survey data from people aged 50 years and over living with and without HIV were analyzed from three study sites in Uganda. Diagnoses of chronic conditions were made through self-report, and disability was determined using the WHO Disability Assessment Schedule (WHODAS). We used ordered logistic regression and calculated predicted probabilities to show differences in the prevalence of multiple chronic conditions across HIV status, age groups, and locality. We used linear regression to determine associations between chronic conditions and the WHODAS. RESULTS: In total, 471 participants were surveyed; about half the respondents were living with HIV. The prevalence of chronic obstructive pulmonary disease and eye problems (except for those aged 60-69 years) was higher in the HIV-positive participants and increased with age. The prevalence of diabetes and angina was higher in HIV-negative participants. The odds of having one or more compared with no chronic conditions were higher in women (OR 1.6, 95% CI 1.1-2.3) and in those aged 70 years and above (OR 2.1, 95% CI 1.2-3.6). Sleep problems (coefficient 14.2, 95% CI 7.3-21.0) and depression (coefficient 9.4, 95% CI 1.2-17.0) were strongly associated with higher disability scores. CONCLUSION: Chronic conditions are common in older adults and affect their functioning. Many of these conditions are not currently addressed by health services in Uganda. There is a need to revise health care policy and practice in Uganda to consider the health needs of older people, particularly as the numbers of people living into older age with HIV and other chronic conditions are increasing.

Improving public health training and research capacity in Africa: a replicable model for linking training to health and socio-demographic surveillance data.

BACKGROUND: Research training for public health professionals is key to the future of public health and policy in Africa. A growing number of schools of public health are connected to health and socio-demographic surveillance system field sites in developing countries, in Africa and Asia in particular. Linking training programs with these sites provides important opportunities to improve training, build local research capacity, foreground local health priorities, and increase the relevance of research to local health policy. OBJECTIVE: To increase research training capacity in public health programs by providing targeted training to students and increasing the accessibility of existing data. DESIGN: This report is a case study of an approach to linking public health research and training at the University of the Witwatersrand. We discuss the development of a sample training database from the Agincourt Health and Socio-demographic Surveillance System in South Africa and outline a concordant transnational intensive short course on longitudinal data analysis offered by the University of the Witwatersrand and the University of Colorado-Boulder. This case study highlights ways common barriers to linking research and training can be overcome. RESULTS AND CONCLUSIONS: This collaborative effort demonstrates that linking training to ongoing data collection can improve student research, accelerate student training, and connect students to an international network of scholars. Importantly, the approach can be adapted to other partnerships between schools of public health and longitudinal research sites.

Reframing vulnerability: Mozambican refugees' access to state-funded pensions in rural South Africa.

Researchers at the South African Medical Research Council/University of the Witwatersrand Rural Public Health and Health Transitions Research Unit (Agincourt) fieldsite in rural South Africa consider Mozambican residents more vulnerable than others in the local population. These self-settled refugees, many of whom are still not South African citizens, primarily came to South Africa in the 1980s during the Mozambican Civil War. This perceived economic vulnerability is rooted in their difficulties in accessing social grants, until recently legally available only to those with South African citizenship documentation. This paper focuses on semi-structured interviews with 30 'older' women of Mozambican-descent living in the Agincourt area. These interviews highlight three important aspects of vulnerability; the respondents: (1) perceive a risk of deportation despite their having lived in the country for 20 years, (2) are unable to easily access social grants, namely the state-funded old-age pension, and (3) struggle to make ends meet when faced with daily needs and crisis situations. All three of these vulnerabilities were mediated to some extent by these women's resourcefulness. They generated ties to South Africa through obtaining identification-documents, used these documents to access pensions, and used the pensions to help them sustain their multigenerational households.

Coping with change: household structure and composition in rural South Africa, 1992 - 2003.

AIM: To describe household change over a 10-year period of tremendous social, political, economic and health transformation in South Africa using data from the Agincourt health and demographic surveillance system in the rural northeast of South Africa. METHODS: Examination of household structure and composition at three points: 1992, 1997, and 2003. These three years loosely represent conditions immediately before the elections (1992), short term post-elections (1997), and longer term (2003), and span a period of notable increase in HIV prevalence. RESULTS: Average household size decreased and the proportion headed by females increased. The within-household dependency ratios for children and elders both decreased, as did the proportion of households containing foster children. The proportion with at least one maternal orphan doubled, but was still relatively small at 5.5%. CONCLUSIONS: This analysis is a starting point for future investigations aimed at explaining how HIV/AIDS and other sociocultural changes post-apartheid have impacted on household organization. The analysis shows both consistency and change in measures of household structure and composition between 1992 and 2003. The changes do not include an increase in various types of "fragile families", such as child-headed or skipped-generation households that might be expected due to HIV/AIDS.

"Taking care of my own blood": older women's relationships to their households in rural South Africa.

AIM: This paper examines financial, emotional, and physical responsibilities elderly women are being asked to take on due to the incapacity of their adult children to care for the next generation; such incapacity is likely to increase as the HIV/AIDS epidemic worsens. METHODS: This paper combines quantitative and qualitative data. Census data from the Agincourt health and demographic surveillance system (AHDSS) describe the presence of the elderly (specifically women over the age of 60 and men over the age of 65) in households in the Agincourt study site. Semi-structured interviews with 30 female residents aged 60-75 complement the census data by exploring the roles that older women, in particular, are playing in their households. RESULTS: An elderly man and/or woman lives in 27.6% of households; 86% of elders live with non-elders. Households with a woman over the age of 60 resident (as opposed to those without) are twice as likely to have a fostered child living in the household and three times as likely to have an orphaned child in the household. Elderly women face financial, physical, and emotional burdens related to the morbidity and mortality of their adult children, and to caring for grandchildren left behind due to adult children's mortality, migration, (re)marriage, and unemployment. CONCLUSIONS: Older women provide crucial financial, physical, and emotional support for ill adult children and fostered and orphaned grandchildren in their households. As more prime-aged adults suffer from HIV/AIDS-related morbidity and mortality, these obligations are likely to increase.