The challenge of ageing with HIV in Africa

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The global introduction and scale up of combination antiretroviral therapy (cART) has transformed HIV infection from a terminal illness into a chronic disease, resulting in increasing numbers of people ageing with HIV. Ageing people living with HIV (PLWH) experience multiple non-communicable diseases (cardiovascular, renal, liver,bone diseases and cognitive decline) and geriatric syndromes such as frailty at higher rates, atchronologically younger age compared to the general population. Although much of the evidence for this has been drawn from high-income countries, non-communicable diseases (NCDs) are already overtaking infections as major burdens of diseases in sub-Saharan Africa (SSA), fuelled, at least in part, by a growing aged and ageing population of PLWH3. With the scale up of ART, SSA has witnessed an increased life expectancy in treated individuals. An estimated three million PLWH in SSA were aged 50 and over in 2011 and this is projected to increase more than three-fold (to 9.1 million) by 2040. Those aged 50 and over will increase from one in seven currently, to one in four of the total PLHIV population, dramatically changing the age structure of PLWH in SSA. This is also the case for Zambia where 89% of the estimated1.2 million PLWH are on cART.

Project description

Ageing PLWH in countries like Zambia are likely to face the full array of health and social challenges commonly associated with ageing in high-income settings, such as decreasing physical mobility,cognitive decline, increased risk for non-communicable disease,and polypharmacy. At the same time stigma and discrimination will create unique challenges for monitoring and provision of health-related care that needs to be addressed. Estimates regarding health care outcomes among ageing PLWH in Zambia such as adherence, and retention into care are lacking/incomplete. Similarly, data on the patterns of chronic conditions, associated risk factors, and associations with disability is limited.

In this complex landscape, the traditional focus on HIV viral suppression as the ultimate goal of HIV care is beginning to give way to additional goals such as health-related quality of life, proposed as the fourth 90 target; the 2014 UNAIDS 90-90-90 targets calls for 90% of all PLWH to be diagnosed, 90% of those diagnosed to receive ART, and 90% of those receiving ART to be virally suppressed. Zambia is now close to achieving those targets (87%-89%-75%) and therefore there is urgent need to understand how to best manage the huge oncoming burden of ageing PLWH and their associated health problems.

To address these challenges, we have developed a theory of change that defines improvement in health-related quality of life of ageing PLWH in Zambia (figure 1) as the main long-term goal. This project seeks support to establish a multidisciplinary and transdisciplinary research partnership that will allow us to increase capacity and capability in Zambia to mobilise research for impact. The support will strengthen the established partnership betweenthe Department of Global Health and Infection at BSMS (Dr Jaime Vera Rojas) andthe Centre for Infectious Diseases Research in Zambia (CIDRZ) (Dr Anjali Sharma, Dr Jake Pry, and Dr Belinda Chihota). The CIDRZ is the largest independent health research organisation in Zambia that has been at the forefront of HIV/AIDS prevention, care and treatment research for over 17 years.

Aims

  • Establish a functional multidisciplinary research network that will refine the theory of change and underpin a programme of work addressing the epidemiology, aetiology, and consequences (economic, psychosocial) of NCDs in HIV with a long-term goal of developing and supporting interventions that will have impact on burden of disease and outcomes for ageing PLWH in Zambia, their families and communities.
  • Strengthen capacity for research excellence, innovation and knowledge exchange between the UK and Zambia.
  • Document service users and service provider’s understandings on NCDs in the context of HIV in Zambia. 
  • Three activities will provide pilot data to support a substantial grant application to address the outcome framework proposed in the theory of change. The activities are underpinned by robust research methodology that will be developed by the multidisciplinary and transdisciplinary team.

Activity 1: Analysis of existing data to determine the clinical outcomes of PLWH with reported multimorbidity

A secondary analysis of existing population data made available through the Zambia national HIV electronic medical records (EMR), will explore the clinical outcomes of people with HIV with multiple chronic diseases (CD4, viral load, AIDS conditions, retention into care, mortality, and adherence) compared to HIV negative people. Chronic conditions to define an individual with multimorbidity will be those reported in the EMR including elevated blood pressure, estimated glomerular filtration rate (eGFR), and obesity (per body mass index). This epidemiological study will explore association between NCDs multimorbidity and HIV clinical outcomes (CD4, AIDS conditions, retention into care, drug resistance, adherence) among PLWH in Zambia and evaluate a primary outcome of multi-morbidity and a secondary outcome of mortality.

Activity 2: Qualitative study to explore what multimorbidity means and what outcomes matter for PLWH and the current experience of management of multimorbidity

A qualitative study will involve in-depth interviews (IDIs) with PLWH and focus groups (FGs) with HIV health care professionals (HCP) including provincial and district medical officers.These activities will inform our understanding of what NCDs and geriatric syndromes mean to PLWH and what outcomes matter most to them including attitudes towards proactive assessment of NCDs and who should assess (general doctor or HIV clinic). For HCP, a separate topic guide will be developed to explore the views on the current standard of care for ageing PLWH and any perceived benefits and potential harms of assessment of NCDs. IDIs and/or FGs of no longer than 90 minutes in duration will be scheduled for PLHIV and HCPs respectively. IDIs and/orFGs will be conducted by a CIDRZ researcher in English or in a local language (Bemba and/or Nyanja) in a confidential research room.

Activity 3: Networking and stakeholder events

We will hold two workshops in Lusaka.

  • Research agenda workshop: All members of the current network will meet to set the research agenda on ageing and HIV with wider participation of other CIDRZ researchers from data management, social science, research ethics, and statisticsas well as CIDRZ staff supporting the National HIV programme. The approach to analysis of activities1 and 2 will also be dicussed.
  • Stakeholder workshop: A second workshop will focus on stakeholders including service providers (HIV and general medicine), government officials, health managers, policy makers, and researchers to refine the proposed theory of change and to share the results of activities 1 and 2. The network will create opportunities for knowledge exchange and capacity building between partner institutions. 

It is envisaged that activities 1, 2 and 3 will provide the necessary information to define the outcomes and develop a strategy to design relevant research studies. The activities will also inform a plan for communication and recruitment of any proposed study. We will hold a minimum of one teleconference every month to ensure all activities are planned and delivered within the timeline.

Timeline and funding

Timeline

April 2020-April 2021
Funding

SSRP-IDCF funding

The team

Where we worked

Field work was conducted in Peru, with additional cases explored in Brazil.