"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.

Understanding Household Dynamics From the Ground Up: A Longitudinal Study From a Rural South African Setting.

Investigations into household structure in low- and middle-income countries (LMICs) provide important insight into how families manage domestic life in response to resource allocation and caregiving needs during periods of rapid sociopolitical and health-related challenges. Recent evidence on household structure in many LMICs contrasts with long-standing viewpoints of worldwide convergence to a Western nuclearized household model. Here, we adopt a household-centered theoretical and methodological framework to investigate longitudinal patterns and dynamics of household structure in a rural South African setting during a period of high AIDS-related mortality and socioeconomic change. Data come from the Agincourt Health and Socio-Demographic Surveillance System (2003-2015). Using latent transition models, we derived six distinct household types by examining conditional interdependency between household heads' characteristics, members' age composition, and migration status. More than half of households were characterized by their complex and multigenerational profiles, with considerable within-typology variation in household size and dependency structure. Transition analyses showed stability of household types under female headship, while higher proportions of nuclearized household types dissolved over time. Household dissolution was closely linked to prior mortality experiences-particularly, following death of a male head. Our findings highlight the need to better conceptualize and contextualize household changes across populations and over time.

Using peer-ethnography to explore the health and well-being of college students affected by COVID-19.

PURPOSE: COVID-19 continues to infect and affect college-aged youth. We lack information about how students experienced the pandemic day-to-day and what they need for recovery, from their own perspectives. This study employed peer ethnography to explore student's insights for current and future prevention and care. METHODS: A team of eight students were trained as peer ethnographers to observe and record conversations with their peers in 15-minute increments during the COVID-19 pandemic. Transcripts of 200 conversations were collated and analysed via theme analysis to identify patterns. RESULTS: Student conversations revealed dichotomous perspectives about COVID-19. Some students prioritized safety, captured via three themes-caution, rethinking routines, and protecting others. Other students struggled to follow prevention guidelines and took risks, also captured by three themes-parties, denial, and misinformation. A third category of themes captured the results of this dichotomy-tense campus relationships and a health leadership vacuum. CONCLUSIONS: Our findings identify specific locations for intervention (e.g., off campus parties) and needed community collaborations (e.g., bars and universities) for COVID-19 and future pandemics. Our findings suggest that overarching approaches, like harm reduction or affirmation (versus shame), are helpful intervention frameworks. Findings also celebrate the value of peer-ethnography, to learn about pandemics and solutions from the ground up.

The effects of HIV and systolic blood pressure on mortality risk in rural South Africa, 2010-2019: a data note.

OBJECTIVES: South Africa is experiencing both HIV and hypertension epidemics. Data were compiled for a study to identify effects of HIV and high systolic blood pressure on mortality risk among people aged 40-plus in a rural South African area experiencing high prevalence of both conditions. We aim to release the replication data set for this study. DATA DESCRIPTION: The research data comes from the 2010-11 Ha Nakekela (We Care) population-based survey nested in the Agincourt Health and socio-Demographic Surveillance System (AHDSS) located in the northeast region of South Africa. An age-sex-stratified probability sample was drawn from the AHDSS. The public data set includes information on individual socioeconomic characteristics and measures of HIV status and blood pressure for participants aged 40-plus by 2019. The AHDSS, through its annual surveillance, provided mortality data for nine years subsequent to the survey. These data were converted to person-year observations and linked to the individual-level survey data using participants' AHDSS census identifier. The data can be used to replicate Houle et al. (2022) - which used discrete-time event history models stratified by sex to assess differential mortality risks according to Ha Nakekela measures of HIV-infection, HIV-1 RNA viral load, and systolic blood pressure.

How Midwestern College students protected their families in the first year of COVID-19.

Introduction: College students routinely visit their families due to geographic proximity and their financial dependence. Consequently, the potential of transmitting COVID-19 from campus to their families' homes is consequential. Family members are key sources of support for one another in nearly all matters but there is little research uncovering the mechanisms by which families have protected each other in the pandemic. Methods: Through an exploratory qualitative study, we examined the perspectives of a diverse, randomly sampled, group of students from a Midwestern University (pseudonym), in a college town, to identify COVID-19 prevention practices with their family members. We interviewed 33 students between the end of December 2020 and mid-April 2021 and conducted a thematic analysis through an iterative process. Results: Students navigated major differences in opinions and undertook significant actions in attempts to protect their family members from COVID-19 exposure. Students' actions were rooted in the greater good of public health; prosocial behavior was on display. Discussion: Larger public health initiatives could target the broader population by involving students as messengers.

"I'm Getting Life from the Treatment": Perceptions of Life and Death Among Middle-Aged and Older Medication-Adherent Persons Living with HIV in Rural South Africa.

The widespread availability of health information and treatment for HIV in Southern Africa does not reach all populations. Few programs and materials are developed with middle-aged and older rural individuals living with HIV as the target audience, despite this being a growing population. This vacuum inevitably exacerbates the disjuncture between clinical and experiential knowledge. This study uses in-depth interviews from 2018 with middle-aged and older rural South Africans who self-report medication adherence to ART in order to explore experiences of living with HIV and beliefs about anti-retroviral treatment (ART). Participants revealed a general sense of vulnerability as a major motivation for HIV medication adherence. A majority of the participants believed that death was imminent if they defaulted on ART at any point in time. Although the availability of ART brought hope to many, HIV was still perceived as a death sentence, particularly if ART adherence was imperfect. The study findings suggest a need to examine the psychosocial component of community programs for middle-aged and older people living with HIV. For this growing population that experienced the full course of the epidemic, more research is needed on the burden of psychological and mental health issues emerging from the need for long-term HIV medication adherence.

Similarities in COVID-19 Mortality Between Canadian Provinces and American States Before Vaccines Were Available.

Canada and the USA are often compared for their markedly different approaches to health care despite cultural similarities and sharing the world's longest international boundary. The period between the onset of the COVID-19 pandemic in January 2020 and the availability of a vaccine in December 2020 offers an ideal opportunity to compare subnational Canadian and American pandemic mortality. Preventing the spread of COVID-19 was through compliance with health orders and best practices; treatment was only available to those admitted to hospitals and whose lives were at risk. Using publicly available data from the Johns Hopkins University 2019 Novel Coronavirus Visual Dashboard, we seek to uncover if there were any similarities in Canadian provinces' and American states' monthly COVID-19 mortality per 100,000 people, building on a broader scientific push towards understanding the successes and failures of different health systems in the pandemic. The similar province and state cumulative COVID-19 mortality rate trajectories identified in our analyses do not amount to intuitive comparative jurisdictions which suggests the importance of identifying localized pandemic responses.

En dépit de leur proximité culturelle et de leur frontière commune, la plus longue au monde, les États-Unis et le Canada font souvent l'objet de comparaisons quant à leurs approches très différentes en matière de soins de santé. La période comprise entre le début de la pandémie de COVID-19 en janvier 2020 et la disponibilité d'un vaccin en décembre de la même année nous offre une occasion idéale de comparer la mortalité pandémique à l'échelle infranationale dans les deux pays. Au cours de cette période, la lutte contre la propagation de la COVID-19 s'est articulée autour du respect des ordonnances de santé et des pratiques exemplaires, les traitements n'étant réservés qu'aux personnes admises dans les hôpitaux dans un état critique. En utilisant les données du tableau de bord de la COVID-19 proposé par l'université John Hopkins, et en nous fondant sur une tendance scientifique plus large visant à comprendre les réussites et les échecs des différents systèmes de santé au cours de la pandémie, nous avons tenté de déceler des similitudes entre les provinces canadiennes et les états américains relativement au nombre de décès mensuel de la COVID-19 pour 100 000 habitants. Les trajectoires similaires des taux de mortalité cumulés liés à la COVID-19 dans les provinces et les états, observées dans nos analyses, ne constituent en aucun cas une comparaison intuitive entre les deux pays, ce qui souligne l'importance d'identifier les réponses locales à la pandémie.

Mitigating the Spread of COVID-19: Differential Perceptions of Midwestern University Students.

Racially minoritized groups have disproportionately borne the impacts of the COVID-19 pandemic in America. We draw on Public Health Critical Race Praxis to investigate racial differences in college students' attitudes about mitigation efforts to limit the spread of COVID-19 and concerns about one's own and others' actions in these efforts. We used survey data from a random sample of Midwestern undergraduates (n = 620) who participated in a fall 2020 COVID-19 study; chi-square tests and logistic regression modeling were employed. Students of color were more likely than white students to report mitigation strategies as not sufficiently restrictive and that communities ought to prioritize limiting the spread of COVID-19. Students of color were also more likely to be concerned that the actions of others were spreading COVID-19. Universities need to continuously ask how their policies and practices acknowledge the broader racial context and seek the perspectives of diverse students.

"COVID Is Another Layer of Problematic Things": Change, Vulnerability, and COVID-19 among University Students.

The COVID-19 pandemic not only had detrimental effects on physical health but also had adverse effects on college students' mental health. This paper begins to fill a gap in knowledge related to the contextual factors that impacted college students' mental health during COVID. Using in-depth interviews with a diverse sample of 33 college students at a Midwestern university, during Spring 2021, we highlight the pandemic's role in shaping college students' mental health and their outlook of the future. Thematic analysis revealed student reports of mental health decline during the pandemic attributed to campus closures and social distancing policies implemented by the institution to reduce the spread of COVID-19. Students shared that the pandemic created uncertainties about their future opportunities for education, career fulfillment, and employment. However, the interviews also suggested a general sense of adaptation to the pandemic's impact which was students achieved via a combination of active and passive coping strategies. Expanding institution-based mental health services to include a variety of modalities and off-line toolkits for students can help students cope with mental health challenges, whether in 'normal times' or during national crises. Future research should focus on identifying strategies for promoting mental wellness among college students and exploring post-pandemic mental health wellbeing.

Undergraduate Vaccine Hesitancy and the Influence of "Home" Locales.

PURPOSE: In the US, the COVID-19 pandemic has exposed deeply rooted resistance to public health. This has important consequences for SARS-CoV-2 variant spread and for future uptake of influenza and other vaccines. We examine these phenomena in Missouri, where its low vaccination rates, high levels of uninsured residents, predominance of conservative values, and stark rural-urban divides are intricately connected to public health resistance. The Socio-Ecological model guides our approach. METHODS: We use data from the Fall 2020 Midwestern University (MWU-a pseudonym) Study of Seropositivity and Risk for SARS-CoV-2 and COVID-19 which are harmonized with the American Community Survey, Missouri County-Level Study, and the USDA Rural-Urban Continuum Codes to estimate multi-level regression models on the relationship between undergraduate students' "home" locales and their own COVID-19 and influenza vaccine hesitancy. FINDINGS: The availability of primary care physicians, the prevalence of influenza vaccinations, and location type at the county level, as well as the percentage of residents without health insurance at the zip code level differentially predict COVID-19 and influenza vaccine hesitancy. CONCLUSIONS: There is a link between county-level health and geographic characteristics, and individuals'-who were influenced by those counties because that is where their parents live-hesitancy towards vaccines. Identifying feasible, precise, local solutions to reducing vaccine hesitancy could take place if community members and other stakeholders would be open to changes in local-level health policy or practice.

Social Support for Improved ART Adherence and Retention in Care among Older People Living with HIV in Urban South Africa: A Complex Balance between Disclosure and Stigma.

The number of older people living with HIV (OPLWH) (aged 50-plus) in South Africa is increasing as people age with HIV or are newly infected. OPLWH are potentially vulnerable because of the intersection of age-related and HIV stigmas, co-morbidities, and lack of social support. Evidence from younger populations suggests that social support can improve ART adherence and retention in care. Further, HIV status disclosure plays a role in mediating social support and may reduce stigma by facilitating access to social support. This paper draws on qualitative research with OPLWH to explore the complex associations between disclosure, social support, and HIV stigma among OPLWH in urban Western Cape. The findings demonstrate that OPLWH receive most of their support from their family and this support can facilitate adherence to ART and retention in care. However, social support is facilitated by participants' disclosure, thus, when perceived stigma limits disclosure, social support is less accessible. Gender, age, and pre-existing vulnerability also affect disclosure to and support from kin and community. Given that social support, particularly from family members, amplifies HIV care access and ART adherence, encouraging disclosure stimulating household HIV competency is likely to both address anticipated stigma and support improved OPLWH's health outcomes.

Who is at Risk? Social Support, Relationship Dissolution, and Illness in a Rural Context.

This study focuses on a cohort of adults (40-plus) in rural South Africa to unpack associations between physical health and receipt of social support, and the extent to which these associations were moderated by marital status. We use logistic regression to estimate the odds of having received emotional, physical, or financial support separately for men (N = 2247) and women (N = 2609). Our results suggest having an Activity of Daily Living (ADL) limitation or having at least one chronic condition was not significantly associated with social support receipt for women, but having an ADL limitation was associated with reduced odds of receiving financial support among men. Although marital status was strongly and significantly associated with receipt of social support for both men and women, marital status moderated the relationship between health indicators and social support receipt only for men. Our findings suggest that when men, but not women, experience a marital dissolution and are suffering from a disability or a chronic condition, their networks respond by providing needed social support.

Twin epidemics: the effects of HIV and systolic blood pressure on mortality risk in rural South Africa, 2010-2019.

BACKGROUND: Sub-Saharan African settings are experiencing dual epidemics of HIV and hypertension. We investigate effects of each condition on mortality and examine whether HIV and hypertension interact in determining mortality. METHODS: Data come from the 2010 Ha Nakekela population-based survey of individuals ages 40 and older (1,802 women; 1,107 men) nested in the Agincourt Health and socio-Demographic Surveillance System in rural South Africa, which provides mortality follow-up from population surveillance until mid-2019. Using discrete-time event history models stratified by sex, we assessed differential mortality risks according to baseline measures of HIV infection, HIV-1 RNA viral load, and systolic blood pressure. RESULTS: During the 8-year follow-up period, mortality was high (477 deaths). Survey weighted estimates are that 37% of men (mortality rate 987.53/100,000, 95% CI: 986.26 to 988.79) and 25% of women (mortality rate 937.28/100,000, 95% CI: 899.7 to 974.88) died. Over a quarter of participants were living with HIV (PLWH) at baseline, over 50% of whom had unsuppressed viral loads. The share of the population with a systolic blood pressure of 140mm Hg or higher increased from 24% at ages 40-59 to 50% at ages 75-plus and was generally higher for those not living with HIV compared to PLWH. Men and women with unsuppressed viral load had elevated mortality risks (men: adjusted odds ratio (aOR) 3.23, 95% CI: 2.21 to 4.71, women: aOR 2.05, 95% CI: 1.27 to 3.30). There was a weak, non-linear relationship between systolic blood pressure and higher mortality risk. We found no significant interaction between systolic blood pressure and HIV status for either men or women (p>0.05). CONCLUSIONS: Our results indicate that HIV and elevated blood pressure are acting as separate, non-interacting epidemics affecting high proportions of the older adult population. PLWH with unsuppressed viral load were at higher mortality risk compared to those uninfected. Systolic blood pressure was a mortality risk factor independent of HIV status. As antiretroviral therapy becomes more widespread, further longitudinal follow-up is needed to understand how the dynamics of increased longevity and multimorbidity among people living with both HIV and high blood pressure, as well as the emergence of COVID-19, may alter these patterns.

From "Secret" to "Sensitive Issue": Shifting Ideas About HIV Disclosure Among Middle-Aged and Older Rural South Africans in the Era of Antiretroviral Treatment.

OBJECTIVE: As HIV shifts from "death sentence" to "chronic condition," disclosure of HIV status to intimate partners and family is a significant component of both prevention and treatment adherence. While disclosure is closely considered in many studies, few examine middle-aged and older persons' (age 40+) perspectives or practices. We trace older rural South Africans' views on HIV disclosure to their partners and family members in a high prevalence community over a period of extensive antiretroviral treatment (ART) rollout. METHODS: Community focus group discussions (FGD) conducted in 2013 and 2018 show shifts in older persons' thinking about HIV disclosure. FINDINGS: Our FGD participants saw fewer negative consequences of disclosure in 2018 than in 2013, and highlighted positive outcomes including building trust (partners) as well as greater support for medication collection and adherence (family). DISCUSSION: Particularly as the epidemic ages in South Africa and globally, tracing changes in older persons' views on disclosure is an important step in developing messaging that could enhance treatment as prevention and ART adherence.

The end of AIDS? HIV and the new landscape of illness in rural South Africa.

The global HIV/AIDS scientific community has begun to hail the dawn of 'the End of AIDS' with widespread anti-retroviral therapy (ART) and dramatic declines in AIDS-related mortality. Drawing on community focus groups and in-depth individual interviews conducted in rural South Africa, we examine the complex unfolding of the end of AIDS in a hard-hit setting. We find that while widespread ART has led to declines in AIDS-related deaths, stigma persists and is now freshly motivated. We argue that the shifting landscape of illness in the community has produced a new interpretive lens through which to view living with HIV and dying from AIDS. Most adults have one or more chronic illnesses, and ART-managed HIV is now considered a preferred diagnosis because it is seen as easier to manage, more responsive to medication, and less dangerous compared to diseases like cancer, hypertension, and diabetes. Viewed through this comparative lens, dying from AIDS elicits stigmatising individual blame. We find that blame persists despite community acknowledgement of structural barriers to ART adherence. Setting the ending of AIDS within its wider health context sheds light on the complexities of the epidemiological and health transitions underway in much of the developing world.

Antiretroviral therapy and aging as resources for managing and resisting HIV-related stigma in rural South Africa.

The widespread roll-out of antiretroviral therapy (ART) in Africa has contributed to a large population of adults aging with HIV. However, little is known about how HIV-related stigma interacts with aging in the ART era. This study uses in-depth interviews with middle-aged and older South Africans living with HIV to explore stigma-related experiences and response strategies. Participants describe a persistence of stigma which requires the deployment of a range of common and age-based stigma management and resistance strategies. We find that participants minimize their exposure to stigma through selective disclosure of their HIV status; neutralize HIV-related stigma through comparisons to chronic illnesses common among older adults, and deflect stigma through asserting an ART-adherent identity and othering younger non-adherent adults. Overall, our study highlights the roles of ART and aging as resources for managing and resisting HIV-related stigma.

'You Have to Withstand That Because You Have Come for What You Have Come for': Barriers and facilitators to antiretroviral treatment access among older South Africans living with HIV.

Nationwide rollout of antiretroviral treatment (ART) is increasing the number of older persons living with HIV (OPLWH) in South Africa. Yet, little is known about how the sociological aspects of ageing - stigma, finances and family dynamics - impact access to ART. Qualitative interviews with 23 persons aged 50-plus living near Cape Town highlight the barriers and facilitators to the acceptability, affordability and availability of ART access among OPLWH. Key age-related barriers included perceived shame of sexuality and disclosing HIV status to others, perceived disrespect by clinical staff, affording transportation to clinics and pre-existing co-morbidities. Key age-related facilitators included family moral and financial support, particularly from children and grandchildren, and access to social grants. Importantly, many barriers and facilitators had feedback loops, for example social grants reduced transportation barriers to clinics when ageing and poor health limited mobility. As the population living with HIV ages, it is critical to assess the ways ageing, as a social process, impacts ART access and to address these to improve older persons' HIV care.

"A NOWADAYS DISEASE": HIV/AIDS AND SOCIAL CHANGE IN A RURAL SOUTH AFRICAN COMMUNITY.

Why do some people adapt successfully to change while others do not? We examine this question in the context of a severe HIV/AIDS epidemic in South Africa, where adapting (or not) to social change has borne life and death consequences. Applying an age-period-cohort lens to the analysis of qualitative life history interviews among middle-aged and older adults, we consider the role of the life course and gendered sexuality in informing Africans' strategies of action, or inaction, and in differentially driving and stalling change in each cohort in response to the HIV/AIDS epidemic. Our study illuminates the unique challenges of adapting to social change that result from dynamic interactions among aging, prevailing social structures, and a cohort's socio-historical orientation to a new period.

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.

Support in times of need: How depressive symptoms can impact receipt of social support among aging adults in rural South Africa.

The relationship between mental health and receipt of social support is not well understood in low- and middle-income countries. In this paper, we focus on a cohort of older adults (40-plus) in rural South Africa to unpack associations between mental health and receipt of social support, and the extent to which marital status modifies these associations. We use baseline data from a population-based study, Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa (HAALSI), conducted between 2014 and 2015. Our results suggest that men and women who report depressive symptoms are less likely to receive social support: women are less likely to receive emotional and financial support, and men are less likely to receive physical and financial support. Both men and women who are married or partnered are more likely to receive social support than their non-married counterparts. The association between depressive symptomology and receipt of social support differs for women who are separated/divorced and for men who are widowed. Specifically, the association between having depressive symptoms and receiving physical or financial support is more positive for separated/divorced women than their married/cohabiting counterparts; for men, the association between having depressive symptoms and receiving physical support is more positive for widowed men than their married/cohabiting counterparts. Our findings speak to the complicated associations between social support, marriage and mental health in later life and the different experiences that men and women may have.