No abstract

The focus of HIV interventions in Botswana, a country with the second highest prevalence of HIV in the world, remains targeted at those aged 15-49 years despite a growing cohort of older people living with the diseasedriven largely by the successful roll-out of antiretroviral therapy (ART). Primarily utilising the Botswana AIDS Impact Survey IV, we set out to examine HIV related characteristics and behaviours of this often ignored older cohort (50-64 years) relative to younger (25-49 years) adults. Analysis revealed that more than 80% of older people living with HIV were on ART. HIV prevalence among this older cohort was 24.6% in 2013 compared to 35.1% among the younger cohort, p < 0.0001. Prevalence in older adults was higher among older males (27.8%) than females (21.9%), p = 0.02. Furthermore, 58.9% of older adults acknowledged being sexually active, with 59.0% of these admitting to inconsistent condom use during sexual intercourse. In addition to this low condom usage, older men (6.0%) were significantly more likely to be unaware of their HIV-positive status than older women (3.0%), p = 0.002. While HIV prevalence showed a dramatic increase among older men over time (17.2% in 2004, to 23.4% in 2008, to 27.8% in 2013), the trend was flatter among older women (16.3% in 2004, to 22.4% in 2008, to 21.9% in 2013). These trends are likely attributable to a large increase in ART coverage and uptake. Going forward, more targeted interventions acknowledging the ageing epidemic are important to consider.

Background: The roll out of antiretroviral therapy in Botswana, as in many countries with near universal access to treatment, has transformed HIV into a complex yet manageable chronic condition and has led to the emergence of a population aging with HIV. Although there has been some realization of this development at international level, no clear defined intervention strategy has been established in many highly affected countries. Therefore we explored attitudes of policy-makers and service providers towards HIV among older adults (50 years or older) in Botswana. Methods: We conducted qualitative face-to-face interviews with 15 consenting personnel from the Ministry of Health, medical practitioners and non-governmental organizations involved in the administration of medical services, planning, strategies and policies that govern social, physical and medical intervention aimed at people living with HIV and health in general. The Shiffman and Smith Framework of how health issues become a priority was used as a guide for our analysis. Results: Amidst an HIV prevalence of 25% among those aged 50–64 years, the respondents passively recognized the predicament posed by a population aging with HIV but exhibited a lack of comprehension and acknowledgement of the extent of the issue. An underlying persistent ageist stigma regarding sexual behaviour existed among a number of interviewees. Respondents also noted the lack of defined geriatric care within the provision of the national health care system. There seemed, however, to be a debate among the policy strategists and care providers as to whether the appropriate response should be specifically towards older adults living with HIV or rather to improve health services for older adults more generally. Respondents acknowledged that health systems in Botswana are still configured for individual diseases rather than coexisting chronic diseases even though it has become increasingly common for patients, particularly the aged, to have two or more medical conditions at the same time. Conclusions: HIV among older adults remains a low priority among policy-makers in Botswana but is at least now on the agenda. Action will require more concerted efforts to recognize HIV as a lifelong infection and putting greater emphasis on targeted care for older adults, focussing on multimorbidity.

Monocytes are phenotypically pliable, which allows them to play several significant immunological roles in combating HIV infection. Monocytes can be subcategorized into subsets based on the expression of CD14 and CD16 antigens. Although the CD4+ T cell counts have been shown to predict HIV viremia, the actual predictive value of these monocyte subsets at different stages of plasma viremia is not known. We derived ex-vivo monocytes from HIV+ patients with detectable and below detectable plasma viremia, HIV+ Long-Term Non-Progressors (LTNP) and HIV negative individuals. We subdivided monocytes into CD14+/ CD16-low, medium and high populations and visualized the phenotypic changes in expression of both CD14 and CD16 antigens in HIV+ patients at different stages of HIV disease.The expression of surface markers on monocytes (CD14+/CD16) was measured from the EDTA blood of 50 HIV+ individuals [14 viremic and 29 Below Detectable Level (BDL) whilst on HAART, 7 therapy naïve, aviremic LTNP's] and 6 HIVnegative donors using the FACSCanto (6-color) flow cytometer. Percentage of CD16/CD14+ sub-populations were measured on FACSCantoA with FACSDiva (v 6.1.2) software and analysed by FlowJo software (v10.0.7), respectively.By categorizing monocyte population into CD14+, CD16 high, medium and low, we could clearly discriminate between viremic and aviremic HIV patients. There was considerable elevation of CD16-low population (80%) in HIV-negative individuals and LTNPS (57%), as opposed to 9% in HAART-treated group. Noteworthy was the CD16-low population failed to recover despite complete viral control during HAART therapy suggesting their definitive role as indicators of viremic control as seen with their marked prominence in LTNPs. In contrast, the HAART-treated group showed elevated CD16-high populations (34%), as opposed to relatively low percentages in the viremic group (3%). The robust maintenance and elevation of CD16-low populations and substantial low levels of CD16-high populations distinctively in HIV-negative and non-progressing HIV+ individuals correlated with the natural control of HIV in LTNPs. This feature of CD16-low monocytic population can be exploited as a biomarker in predicting plasma viremia and the strength of the immune system.