Ageing with HIV: Psychological and Functional Wellbeing and its 
biopsychosocial determinants at the Kenyan coast 

 
  

 

 

By 

PATRICK NZIVO MWANGALA 

A Thesis Submitted to the Faculty of Health Sciences,  

The University of the Witwatersrand 

Johannesburg, South Africa 

in fulfilment of the requirements for the Degree of  

DOCTOR OF PHILOSOPHY  

06 November 2024 

 

 



ii 
 

DECLARATION 
 

I, Patrick Nzivo Mwangala, declare that this PhD thesis is my own, unaided work, 

except where specific references cited to the work of others. It is being submitted for the 

Degree of Doctor of Philosophy degree at the University of the Witwatersrand, 

Johannesburg. It has not been submitted before for any degree or examination at any 

other university. 

 

 

 

(Signature of candidate) 

Date: 6th day of November 2024 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



iii 
 

DEDICATION 
 

This research is dedicated to my loving family, particularly to my mother, Naomi Mnyazi, 

who taught me the value of education even though she never had the chance to go to 

school; my elder brother, John Mrima, for constantly fanning into flame the spirit of 

excellence in me; my wife Nancy for her prayers, support and understanding during my 

academic and research career; and my daughter Nylah whose arrival has made me 

stronger, better, and more fulfilled. To my Heavenly Father, all glory and honour is unto 

you. I testify of your providence, strength, wisdom, inspiration, faithfulness, and all-

sufficient grace! 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



iv 
 

Thesis Abstract 
Background:  

Kenya, and sub-Saharan Africa (SSA) in general, are experiencing rapid demographic 

transitions, including the ageing of the HIV population. Intuitively, this has created a 

subgroup of vulnerable older adults living with HIV (OALWH) requiring an urgent 

response in research, policy, and programming to mitigate their complex and 

transitioning needs. Existing evidence on HIV and ageing, largely from European cohort 

studies, demonstrates that OALWH are vulnerable to ill health, especially psychological 

morbidities (e.g. mental and cognitive impairments), geriatric syndromes (e.g. frailty) 

and multimorbidity. For the last decade, the SSA region has witnessed noteworthy 

progress in ageing and health, e.g. the establishment of health and ageing cohorts in 

South Africa. Yet, current evidence on mental, cognitive, and geriatric syndromes 

among OALWH is inadequate from the region partly because of heterogeneous 

findings, few well-designed studies, and significant methodological limitations, e.g. small 

sample sizes, lack of comparison groups and few adapted/validated measurement 

tools. In Kenya, HIV and ageing is an emergent subject, and little is known about the 

burden and determinants of these impairments.  

To address some of these research gaps, this PhD thesis sets out to:  

(a) Understand the health challenges faced by OALWH and the coping strategies they 

use to confront these challenges on the Kenyan coast,  

(b) Document the burden and associated factors of common mental disorders (CMDs) 

and frailty among OALWH compared to their HIV-uninfected peers on the Kenyan 

coast,  

(c) Examine the acceptability, reliability, and validity of a local (Swahili) measure of 

cognitive function, the Oxford Cognitive Screen Plus (OCSPlus), among older adults 

and provide a preliminary understanding of their cognitive performance (by HIV 

status) and associated factors.   

 

 



v 
 

Methodology:  

We used a mixed methods research design to answer our research questions, 

employing both qualitative and quantitative approaches. The qualitative phase of the 

study recruited 34 OALWH receiving routine HIV care and treatment, together with their 

healthcare providers (n=11) and primary caregivers (n=11). Qualitative data were drawn 

from semi-structured in-depth interviews that were audio-recorded, transcribed 

verbatim, and analyzed using the framework approach. Data management was done in 

Nvivo software. The quantitative phase, a cross-sectional survey, involved 440 older 

adults aged ≥50 years (58% OALWH). Locally adapted and/or validated tools were used 

to assess CMDs, frailty and cognitive function. All quantitative analyses were conducted 

using STATA software. Proportions were used to estimate the prevalence of CMDs and 

frailty among OALWH and their HIV-uninfected peers. Logistic regression was used to 

examine the factors associated with CMDs and frailty. Different psychometric tests were 

used to assess the reliability and validity of the OCSPlus tool. Test-retest reliability was 

evaluated using intra-class correlations. We computed Pearson correlation coefficients 

to assess convergent validity between OCSPlus and conventional cognitive tests. 

Multiple linear regressions were used to examine correlates of cognitive function.  

Results:  

Our findings from the qualitative phase showed that OALWH face multiple mental health 

challenges (e.g. symptoms of depression, anxiety, cognitive complaints) and physical 

health challenges (e.g. hypertension, diabetes, ulcers, somatic symptoms, and 

functional impairments), which were often complicated by a host of psychosocial 

challenges including food insecurity, ageism, HIV-related stigma, loneliness, and 

financial difficulties. Many of the perceived risk factors for these challenges were 

observed to overlap across the three health domains. Five major themes emerged from 

analyzing participants’ narratives on coping strategies, including self-care, positive 

religiosity, social connectedness, generativity and identity and mastery. Our findings 

also revealed maladaptive coping strategies, including self-isolation, over-reliance on 

over-the-counter medication, delayed healthcare seeking and skipping meals and 

medications. In the cross-sectional dataset, we found no significant differences in the 



vi 
 

prevalence of mild depressive symptoms (24% vs 18%) and anxiety symptoms (12% vs 

7%) among OALWH compared to their uninfected peers, respectively. However, the 

prevalence of frailty was significantly higher among OALWH (24%) than their uninfected 

peers (13%). After adjusting for biopsychosocial factors, HIV seropositivity was not 

independently associated with CMDs or frailty. In multivariable analyses, the factors 

associated with increased odds of CMDs and frailty included HIV-related stigma, 

ageism, loneliness, functional impairment, sleeping difficulties, increasing household 

HIV burden, chronic fatigue, increasing medication burden, advanced age (>70 years), 

higher waist/hip ratio, visiting traditional healers, history of combination antiretroviral 

therapy (cART) regimen change/interruption, and prolonged illness following HIV 

diagnosis. In contrast, factors associated with reduced odds of CMDs and frailty 

included easier access to an HIV clinic, residing in larger households, higher household 

income, having a social network of friends, and being physically active. Most of these 

factors were corroborated in the qualitative phase of the study. In our last objective, the 

OCSPlus measure was found to be acceptable, reliable, and valid. Concerning cognitive 

performance, OALWH presented with significantly lower mean scores on language and 

executive function compared to their uninfected peers; however, they (OALWH) 

performed significantly better on memory. Several factors ranging from behavioural and 

lifestyle, sociodemographic, medical or treatment factors and psychosocial factors were 

significantly associated with cognitive performance (using OCSPlus).  

Discussion:  

Due to effective antiretroviral therapy (ART), people living with HIV are ageing, and this 

is witnessed across the world wherever ART is readily available. While this represents 

the success of HIV care and treatment, those ageing with HIV confront numerous health 

challenges, some of which are unique to this population, as observed in this study. 

Older adults living with HIV on the Kenyan coast are vulnerable to mental, cognitive, 

and functional health challenges, which appear to be complicated by several 

psychosocial challenges. Despite the observed health challenges, OALWH are able to 

integrate several positive strategies to promote or address their mental health and well-

being. The findings of this study are timely in addressing some of the existing gaps in 



vii 
 

understanding the mental, cognitive, and functional health of OALWH in the country and 

set the stage for further research and the development of relevant interventions and 

healthcare strategies to improve the care of these adults.  

OALWH need to be recognized as an unique subpopulation requiring targeted health 

and social services, given the unique health challenges observed in this study. 

Relatedly, there is a need to build the capacity of healthcare providers, for instance, in 

the screening and management of CMDs and frailty, at least for the OALWH at risk of 

poor health outcomes, e.g., those facing multiple psychosocial challenges and 

deteriorating HIV treatment indicators. The majority of healthcare providers interviewed 

in the qualitative phase lamented their lack of skills and capacity to screen and manage 

CMDs and cognitive impairments. Additional support may include helping OALWH and 

their caregivers to mobilize social support and referrals, where possible, to relevant 

institutions and increase access to basic needs and services. The Kenya HIV 

prevention and treatment guidelines also need to be updated to highlight the unique 

needs of OALWH, e.g. multimorbidity. Different models of care have been 

recommended for the care of OALWH, including comprehensive geriatric assessment 

and integration of chronic care services into routine HIV care services. Formative work 

can be conducted to assess the possibility of introducing these models into care. Future 

work needs to ascertain the cause-and-effect association of the reported correlates and 

carry out formative work on the feasibility of multicomponent psychological and physical 

interventions to address identified health problems, e.g. psychosocial challenges, CMDs 

and frailty.  

 

 

 

 

 

 

 



viii 
 

Preface 
 

This thesis is submitted to the University of the Witwatersrand, Faculty of Health 

Sciences, for the fulfilment of the requirements for the degree of Doctor of Philosophy 

by publication in the major area-subject of Public Mental Health. The doctoral research 

has been undertaken at the School of Public Health. My supervisors were Professor 

Amina Abubakar, Dr. Ryan Wagner, and Professor Charles Newton.  

This doctoral work was supported by the Wellcome Trust International Master's 

Fellowship to the doctoral candidate (Grant number 208283/Z/17/Z). Further funding 

supporting this work was from: 1) the Medical Research Council - MRC (Grant number 

MR/M025454/1) to Amina Abubakar. This award is jointly funded by the UK Medical 

Research Council and the UK Department for International Development (DFID) under 

MRC/DFID concordant agreement and is also part of the EDCTP2 program supported 

by the European Union; 2) The Institute for Human Development at the Aga Khan 

University, Kenya; 3) DELTAS Africa Initiative [DEL-15-003]. The DELTAS Africa 

Initiative is an independent funding scheme of the African Academy of Sciences (AAS)'s 

Alliance for Accelerating Excellence in Science in Africa (AESA) and supported by the 

New Partnership for Africa's Development Planning and Coordinating Agency (NEPAD 

Agency) with funding from the Wellcome Trust [107769/Z/10/Z] and the UK government. 

 

 

 

 

 

 

 

 

 



ix 
 

Presentations arising from this research study 
 

1) Mwangala PN, Mabrouk A, Wagner RG, Newton CR, Abubakar A. A Systematic 

Review of Health and Wellbeing in older adults living with HIV in Sub-Saharan Africa 

(abstract oral presentation at the 11th KEMRI Annual Scientific & Health (KASH) 

Conference – 8th to 10th June 2021 – held virtually).  

 

2) Mwangala PN, Wagner RG, Newton CR, Abubakar A. Navigating life with HIV as an 

older person at the Kenyan coast: perceived health challenges seen through the 

biopsychosocial challenges. (e-poster presented at the 2021 International Workshop 

on HIV & Aging held virtually from 23rd to 24th Sept 2021).  

 

3) Mwangala, PN. Mental health and wellbeing of vulnerable older people in a Kenyan 

rural setting (delegate for the McGill University's workshop on Community-based 

Mental Health interventions: Critical perspectives and innovative approaches held 

virtually from 6th to 9th April 2021).  

 

 

 

 

 

 

 

 

 

 



x 
 

Publications arising from this research study 
 

My contribution in the PhD research work includes being the first author in the following 

publications. In the larger PhD project, I designed and took the lead in the acquisition of 

research ethics and permits, trained research assistants, monitored data collection and 

community-engagement and performed data management, conducted data analysis, 

wrote the first drafts of manuscripts and implemented the contributions of the co-authors 

and external reviewers up to final publication. During the process, I asked for and 

implemented input and feedback from supervisors.  

1) Mwangala PN, Mabrouk A, Wagner RG, Newton CR, Abubakar A. Mental health 

and well-being of older adults living with HIV in sub-Saharan Africa: a systematic 

review. BMJ Open. 2021 Sep 1;11(9):e052810.  

doi: https://doi.org/10.1136/bmjopen-2021-052810 

 

2) Mwangala PN, Wagner RG, Newton CR, Abubakar A. Navigating life with HIV as an 

older adult on the Kenyan coast: perceived health challenges seen through the 

biopsychosocial model. International Journal of Public Health. 2023;68:1605916.    

doi: https://doi.org/10.3389/ijph.2023.1605916 

 

3) Mwangala PN, Wagner RG, Newton CR, Abubakar A. Strategies for improving 

mental health and wellbeing used by adults ageing with HIV: a qualitative 

exploration. Wellcome Open Research. 2022;7(221):1.                                            

doi: https://doi.org/10.12688/wellcomeopenres.18212.2 

 

 

4) Mwangala PN, Nasambu C, Wagner RG, Newton CR, Abubakar A. Prevalence and 

factors associated with mild depressive and anxiety symptoms in older adults living 

with HIV from the Kenyan coast. Journal of the International AIDS Society. 2022 

Sep;25:e25977. doi: https://doi.org/10.1002/jia2.25977 

 

https://doi.org/10.1136/bmjopen-2021-052810
https://doi.org/10.3389/ijph.2023.1605916
https://doi.org/10.12688/wellcomeopenres.18212.2
https://doi.org/10.1002/jia2.25977


xi 
 

 

5) Mwangala PN, Nasambu C, Wagner RG, Newton CR, Abubakar A. Prevalence and 

Factors Associated With Frailty Among Older Adults Living With HIV Compared to 

Their Uninfected Peers From the Kenyan Coast. International Journal of Public 

Health. 2024;69:1606284. doi: https://doi.org/10.3389/ijph.2024.1606284 

 

 

6) Mwangala PN, Nasambu C, Wagner RG, Duta M, Demeyere N, Scerif G, Newton 

CR, & Abubakar A. Neurocognitive functioning among adults ageing with and 

without HIV at the Kenyan Coast: Measurement issues and correlates. 2024 

(Undergoing interactive review among coauthors). 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

https://doi.org/10.3389/ijph.2024.1606284


xii 
 

Acknowledgements 
 

Where there is no guidance, the people fall, but in the abundance of counsellors, there 

is victory! I would not have come this far were it not for the immense guidance, support, 

counsel, and encouragement from several people that I would like to recognize.  

My supervisors, Prof. Amina Abubakar, Dr. Ryan Wagner and Prof. Charles Newton. 

Amina, thank you very much for seeing my potential and believing in me since joining 

the KEMRI-Wellcome Trust Research Programme (KWTRP) back in Jan 2016. Your 

encouraging words, support and presence have been pivotal throughout my research 

profession. You have done a fantastic job as my academic mentor, supervisor, and 

‘academic mother’. It has been eight wonderful years of research experience, and still 

counting! A big thank you for your encouragement and guidance during the low 

moments in my research career – including paper rejections, missing the first MSc 

fellowship application, and the long search for an external PhD supervisor, which took 

almost a year, to mention a few. Thank you for all the link-ups, introductions, 

collaborations, and connections that have positively contributed to my research career. 

Charles, I am grateful for your enthusiasm regarding my professional growth. You have 

consistently shown unwavering support for all my endeavours in pursuing further 

education. Even during my pursuit of a PhD, you have persistently offered valuable 

guidance and thorough feedback. I sincerely appreciate your continuous presence and 

assistance. Ryan, I appreciate your confidence and belief in me when you agreed to 

mentor me as your PhD student, even when you knew little about me. Your enthusiasm, 

critical feedback, and availability have contributed immensely to my growth and made 

my PhD journey bearable! Despite being thousands of miles away from Johannesburg, 

your invaluable support at the school has always made me feel I am right there. Many 

thanks for knocking on those many doors, writing those many emails, showing me 

where to go for assistance, and always making time for me. A true friend you are, 

ngiyabonga kakhulu!  

My PhD advisors and mentors (Studentship Monitoring and Appraisal Committee at 

KEMRI Kilifi), Drs. Benjamin Tsofa, Symon Kariuki and Derrick Ssewanyana. Thank you 



xiii 
 

for willingly accepting this role. Your meticulous feedback and constant encouragement 

are greatly appreciated! Thank you for taking the time to listen to my concerns and 

offering valuable insights and guidance.  

Derrick, you were present when I began my research career back in 2016 when you 

were beginning your PhD journey. You have been the elder scholarly brother throughout 

my research journey, and I have learnt a lot from you. I remember the statistical support 

you gave me in my postgraduate diploma research study, which went on to become the 

best research study in my cohort, enabling me to graduate with distinction. Thank you 

for polishing my research skills, e.g. manuscript writing and publication, communication 

and how to ace those interviews! Besides research and office, I cherish the great 

memories we created in Kilifi, the evening walks, and occasional outings. All the very 

best in your endeavours!  

To my colleagues, officemates and buddies at Neuro Department Moses, Dorcas, and 

Patricia, you are a God send. I appreciate the constant encouragement and support. 

Our informal talks at the office were a great joy! It’s a pleasure to have met you. Moses 

and Dorcas, thank you for leading the way and showing us it can be done, and 

obstacles are there to be conquered! Patricia, cheers to us for remaining on course and 

coming to the finish line! To my friend and colleague Adam Mabrouk, who did not have 

the chance to see the fruition of this adventure, you will forever be in my memories! A 

special appreciation to my friends and colleagues at Wits University for equally cheering 

me on. Paul Bohloko, many thanks for always being there to clarify things and for the 

extended support throughout this journey. God bless you!  

To the field team Khamis Katana, Katana Ngombo, Beatrice Kabunda, Richard Karisa, 

Sadaka Charo, Mama Achila, Haprity Mwangata, Irene Kasichana, and Maureen 

Sikubali, you made this PhD work a reality. Many thanks for your unwavering support, 

commitment, and sacrifices throughout the data collection period. I would like to 

recognize the support, in one way or another, from the following colleagues at the Neuro 

department: Judy Tumaini, Collins Kipkoech, Vincent Amukumbi, Eva Mwangome, Mary 

Bitta, Jonathan Abuga, Stevenson Chea and Stanley Wanjala.   



xiv 
 

Data managers Carophine Nasambu and Paul Mwangi, a big thank you for your support 

with data management, without which I would not have published a single paper from 

this work. Paul, I am grateful for the additional advice you provided on my analytic 

plans.  

To my colleagues at the Institute for Human Development, I may not mention you by 

name, but you are close to my heart! Thank you for welcoming me into the IHD family in 

2022. You have been instrumental in my success so far, always there to help, guide and 

support. I have learnt a lot from you. To Esther Chongwo, Faith Neema, Sabina Odero, 

Beatrice Mkubwa, and Joyce Marangu, all the very best as you continue with your 

PhDs.  

To the Mnyazi family, the Mrimas’, Mwatatas’, Karisas’, Kunyu’s, Muhache, Nikengo, 

and Wani, God bless you for cheering me on and your continued prayers in all my 

endeavours. Mum, you are one in a million! May God add more life to your years and 

continue inspiring generations! Mrima, thank you for always checking on my progress 

and constant encouragement. This is the first of many in the family. To Mwatata and 

Phanice, the mantle is now in your hands! All the best in the line of duty as you continue 

with your PhDs!  

To my loving wife, Nancy, a special thank you for standing by me through my labors, my 

absences, and impatience. Receive my heartfelt appreciation for your love and constant 

support, for all the late nights, early mornings and for keeping me sane these past few 

years. You are my muse, inspiration, and sounding board, and, most of all, my best 

friend! Thank you for the countless sacrifices to get me this far. Cheers!  My daughter 

Nylah, thank you for providing me with the requisite breaks from research and the 

motivation to complete my studies on time.  

To the Almighty God, all this would not make any sense without you! Your grace and 

providence have been more than sufficient. Thank you for working behind the scenes 

and aligning everything to this fruitful end. All glory and honour be unto you!  

 



xv 
 

Table of Contents 
DECLARATION ........................................................................................................................... ii 

DEDICATION ............................................................................................................................. iii 

Thesis Abstract .......................................................................................................................... iv 

Preface .................................................................................................................................... viii 

Presentations arising from this research study ........................................................................... ix 

Publications arising from this research study .............................................................................. x 

Acknowledgements ................................................................................................................... xii 

List of Figures .......................................................................................................................... xvi 

List of Tables ........................................................................................................................... xvii 

List of Abbreviations ................................................................................................................. xix 

Chapter 1 .................................................................................................................................. 1 

General Introduction                                                                                                                      1 

Chapter 2 .................................................................................................................................30 

Navigating life with HIV as an older adult on the Kenyan coast: perceived health challenges 

seen through the biopsychosocial model                                                                                    30 

Chapter 3 .................................................................................................................................58 

Strategies for improving mental health and wellbeing used by adults ageing with HIV from the 

Kenyan coast: a qualitative exploration                                                                                       58 

Chapter 4 .................................................................................................................................84 

Prevalence and factors associated with mild depressive and anxiety symptoms in older adults 

living with HIV from the Kenyan coast                                                                                         84 

Chapter 5 ............................................................................................................................... 111 

Prevalence and factors associated with frailty among older adults living with HIV compared to 

their uninfected peers from the Kenyan coast                                                                           111 

Chapter 6 ............................................................................................................................... 138 

Assessing neurocognitive functioning among adults ageing with and without HIV at the Kenyan 

Coast: Measurement issues and correlates                                                                              138 

Chapter 7 ............................................................................................................................... 165 

Integration of key results across the PhD thesis manuscripts and General Discussion            165 

References ............................................................................................................................ 193 

Appendix ............................................................................................................................... 220 

Ethics Approval ....................................................................................................................... 220 

In-depth interviews  ................................................................................................................. 221 

Published papers  ................................................................................................................... 226 

 



xvi 
 

List of Figures 
 

Figure 1.1: HIV prevalence across the world in 2021 .......................................................... 7 

Figure 1.2. Number of older adults living with HIV who are aged ≥50 years in HICs and  

LMICs, 2000 – 2020. Source: Autenrieth, Christine S., et al ..............................................10 

Figure 1.3. A map of Mombasa and Kilifi counties and study recruitment sites ...............25 

Figure 2.1: Components of the Biopsychosocial Model of Health (Kilifi County, Kenya. 

2019)........................................................................................................................................34 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



xvii 
 

List of Tables 
 

Table 1.1. A highlight of the sources of data, applied measures and primary outcomes in 

the different thesis chapters ..................................................................................................28 

Table 2.1: Sociodemographic and clinical characteristics of older adults living with HIV 

(Kilifi County, Kenya. 2019). ..................................................................................................37 

Table 2.2: Perceived forms of physical, mental, and psychosocial health challenges 

facing older adults living with HIV as discussed by study participants (Kilifi County, 

Kenya. 2019). .........................................................................................................................39 

Table 2.3: Participants' physical health challenges quotes (Kilifi County, Kenya. 2019). 41 

Table 2.4: Participants’ mental health quotes (Kilifi County, Kenya. 2019). ......................44 

Table 2.5: Participants' psychosocial challenges quotes (Kilifi County, Kenya. 2019). ...48 

Table 3.1. Sociodemographic and clinical characteristics of older adults living with HIV 65 

Table 3.2. Participants' quotes on perceived coping strategies for mental and well-being 

challenges ...............................................................................................................................68 

Table 4.1. Characteristics of the study population by HIV status, n = 440 .......................92 

Table 4.2 HIV-related clinical and psychosocial characteristics of OALWH, n = 257 ......94 

Table 4.3. Prevalence of common mental disorders in OALWH versus their HIV-negative 

peers ........................................................................................................................................95 

Table 4.4 Association between HIV status and common mental disorders across the 

whole sample of older adults .................................................................................................97 

Table  4.5 Univariate and multivariable  analysis of correlates of common mental 

disorders among OALWH ......................................................................................................99 

Supplementary Table 4.1. Univariate and multivariable  analysis of  the correlates of 

depressive symptoms among HIV-negative older adults ................................................. 109 

Table 5.1: Characteristics of the study population by HIV status, n = 440 (Kenyan coast. 

2020 & 2021) ........................................................................................................................ 120 

Table 5.2: HIV-related, clinical, and psychosocial characteristics of OALWH, n = 257 

(Kenyan coast. 2020 & 2021) .............................................................................................. 122 

Table 5.3: Prevalence of frailty in OALWH versus their uninfected peers (Kenyan coast. 

2020 & 2021) ........................................................................................................................ 124 

Table 5.4: Association between HIV status and frailty among older adults (Kenyan coast. 

2020 & 2021) ........................................................................................................................ 125 

Table 5.5: Univariate and multivariable analysis of correlates of frailty among OALWH 

(Kenyan coast. 2020 & 2021) .............................................................................................. 126 



xviii 
 

Table 5.6: Univariate and multivariable analysis of correlates of frailty among HIV-

uninfected older adults (Kenyan coast. 2020 & 2021) ...................................................... 129 

Table 6.1. Perceived degree of difficulty or ease on various OCSPlus tests from 

respondents .......................................................................................................................... 150 

Table 6.2. Intra Class Correlations for the different OCSPlus subtasks.......................... 151 

Table 6.3. Cronbach alphas for some of the OCSPlus subtasks ..................................... 151 

Table 6.4. Correlations between OCSPlus and the conventional tests (n=440) ............ 152 

Table 6.5. Cognitive profile on conventional and OCSPlus cognitive tests, according to 

HIV status (adjusted means, n=440) .................................................................................. 153 

Table 6.6. Multiple linear regression model showing the association of OCSPlus raw 

scores with biopsychosocial variables among OALWH .................................................... 156 

Table 6.7. Multiple linear regression model showing the association of OCSPlus raw 

scores with biopsychosocial variables among HIV uninfected older adults ................... 158 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



xix 
 

List of Abbreviations 
 

AMPATH – Academic Model Providing Access to Healthcare 

AIDS – acquired immunodeficiency syndrome  

ART – antiretroviral therapy 

CBO – Community-based organization  

CD4 count – Clusters of differentiation 4 

cART – combination antiretroviral therapy 

CMDs – common mental disorders 

COVID-19 – coronavirus disease 

GAD-7 – 7-item Generalized Anxiety Disorder scale 

GPS – Global Positioning System  

HICs – High-Income Countries 

HAND – HIV-associated neurocognitive impairment  

HIV – human immunodeficiency virus 

ICOPE – Integrated Care for Older People 

IHDS – International HIV Dementia Scale  

UNAIDS – Joint United Nations Programme on HIV/AIDS  

KEMRI – Kenya Medical Research Institute  

KWTRP – KEMRI-Wellcome Trust Research Programme 

KCH – Kilifi County Referral Hospital  

KHDSS – Kilifi Health and Demographic Surveillance System 

LMICs– Low-and-Middle-Income Countries   



xx 
 

OR – Odds Ratio  

OALWH – older adults living with HIV  

OCS-EF – Oxford Cognitive Screen: Executive Function 

OCSPlus – Oxford Cognitive Screen Plus 

PHQ-9 – 9-item Patient Health Questionnaire 

PLWH – people living with HIV  

RSPM – Ravens Standard Progressive Matrices 

REDCap – Research Data Capture platform 

SSA – sub-Sharan Africa  

UN – United Nations 

US – United States of America 

WHO – World Health Organization  

WHODAS – World Health Organization Disability Assessment Schedule



1 
 

 

 

 

Chapter 1 
 

 

 

 

 

 

 

General Introduction 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



2 
 

1.1. Chapter outline 

This thesis is built around five separate but related papers. The first two papers aim to 

understand the health challenges experienced by older adults living with HIV (OALWH) 

on the Kenyan coast and the coping strategies they use to confront these challenges. 

The third and fourth papers document the prevalence and correlates of common mental 

disorders (CMDs) and frailty among OALWH compared to their HIV-uninfected peers in 

the same setting. The last paper reports on the validation of a local (Swahili) measure of 

neurocognitive function and subsequently examines the neurocognitive function of 

these adults.  

The current chapter (structured into 11 subsections) largely collates the most recent 

literature on mental, cognitive, and functional (frailty) health problems in the context of 

HIV. Other supporting sub-topics are also highlighted to contextualize the main study 

themes. The chapter begins by defining an older adult in the general population and HIV 

literature in section 1.2. Subsequently, a brief profile of older adults globally and in 

Kenya is discussed in section 1.3. This section is followed by an overview of the current 

HIV burden (section 1.4), older adults and HIV (section 1.5), challenges of living with 

HIV as an older adult (section 1.6), overview of the comorbidity of HIV and mental, 

cognitive, and geriatric disorders (section 1.7), the burden and associated factors of 

mental, cognitive, and geriatric disorders comorbid with HIV (section 1.8), and the 

adverse outcomes of HIV comorbid with mental and geriatric disorders (section 1.9). In 

the second last section (1.10), the existing research gaps and justification for the current 

PhD study are highlighted. The last section of this chapter (1.11) describes, in detail, the 

present PhD study, identifying the study objectives, design, setting, and data sources. 

The chapter then closes with an outline of the structure for the remainder of the thesis.  

1.2. Definition of an older adult in the general population and HIV literature 

There is currently no consensus on the chronological age at which an individual 

becomes old, partly because the ageing process is asynchronous and heterogeneous. 

Various age thresholds have been used to define old age in the general population: e.g., 

≥60 years by the United Nations and the African Union Policy Framework and Plan of 

Action on Ageing (1), and ≥65 years in the United States – US and Europe (2). Notably, 



3 
 

the World Health Organization (WHO) has recommended a lower cut-off, ≥50 years, to 

define older people in sub-Saharan Africa (SSA) to accommodate some of the 

definitional complexities, e.g. reduced life expectancy, cultural/social roles, and 

functional/biological abilities (3, 4). Consistent with the United Nations and African Union 

definitions, Kenya has adopted the definition of older people as those aged ≥60 years.  

Different age thresholds have also been used to define medically advanced old age 

among people living with human immunodeficiency virus (HIV), ranging from 45 to 65 

years, with 50 years being the most frequently utilised cut-off (5-8). This distinction is 

based on evidence of poorer immunological response to antiretroviral therapy – ART (5, 

9), early immunosenescence and its premature deleterious effect on physiological 

functions and clinical consequences (10), early-onset geriatric syndromes such as frailty 

(11) and elevated mortality (5, 12) in these adults. In this thesis, an older person will be 

defined as anyone aged ≥50 years unless otherwise specified.   

In Kenya, the number of adults aged ≥50 years is projected to nearly quadruple by 

2050, making it one of the most rapidly ageing nations in SSA, thus underscoring the 

need for meaningful investments in healthy ageing in the country. The significant 

increase in the number of older adults in Kenya, like many countries in SSA, has been 

attributed to increasing life expectancy, improving healthcare and declining fertility rate 

in the region (13). 

1.3. The profile of older people globally and in Kenya 

Every nation in the world is experiencing a rise in both the size and the proportion of 

older people in its population – some are at its early stages, e.g. Kenya, while others 

are more advanced and have larger proportions of the elderly, e.g. Japan (14). Globally, 

the number of people aged ≥50 years was about 1.1 billion in 2000 and is predicted to 

increase nearly three-fold to 3.2 billion by 2050 (15). This demographic "megatrend" is 

projected to become more pronounced in Low-and-Middle-Income Countries (LMICs),  

especially in SSA, with lasting impacts on health, e.g. shifting disease burden and rising 

expenditure on health and long-term care (14). Therefore, understanding the physical, 

mental, and social wellbeing of older people has become a global health priority, largely 

motivated by the observed and projected trends of population ageing. For instance, for 



4 
 

the first time ever, people aged ≥60 years have outnumbered children <5 years in 

several countries in the world (16). Additionally, the proportion of older people is 

expected to continue to rise even in regions such as SSA, where the HIV epidemic 

caused significant reduction in life expectancy in the 1990s and early 21st century (13). 

Kenya, like many countries in SSA, is experiencing demographic and epidemiologic 

transitions where the share of the country's population aged ≥50 years is growing 

rapidly (17). The increasing incidence of chronic ageing-related conditions (18) is 

coinciding with a high prevalence of HIV among older adults (19). The country is 

expected to see an increase in the population aged ≥50 years from 2.1 million (6.8%) in 

2000 to 15.1 million (17.7%) in 2050, with those aged ≥65 years rising five-fold from 1 

million to 5.1 million over the same period (15). That is, nearly 1 in 5 of the total 

projected Kenyan population in 2050 will be aged ≥50 years, up from 1 in 15 in 2000. 

Older people are the fastest-growing population segment in Kenya (20).  

Within SSA, the concern of population ageing is not just based on its close association 

with adverse health impacts such as multimorbidity, but on the recognition that the 

majority of the existing policies on healthy ageing, if existent, are rarely implemented, 

and many older people are neglected, and prone to abuse (21). Moreover, ageing takes 

place against a backdrop of chronic poverty, income insecurity, adult unemployment, 

high rates of HIV-related morbidity and mortality, inadequate health services (both 

preventive and curative services), insufficient/unsustainable welfare and social 

protection programs, lack of both formal and informal care providers (e.g. nursing 

homes) in addition to changing cultural and familial norms regarding the duties and 

obligations by and towards older people (22, 23). According to the most recent report on 

the state of Kenyan population, dubbed "population anxiety in Kenya", more than half of 

the older people are documented to live in absolute poverty and constitute the poorest 

group in the country (20). In this report, the majority of old Kenyans reside within 

multigenerational households in rural settings, slightly more than half (55%) are women, 

approximately 60% are married, over a third are widowed, 21% live alone, and 11% live 

with minors. The older people’s perceptions of old age revolve around food insecurity, 

worries about support and care, health issues, financial insecurity and feeling displaced 



5 
 

in a modern, globalized world, e.g., left alone and not consulted for advice by younger 

people (20).     

To date, Kenya also lacks a long-term public health insurance scheme for older people, 

and access to private health insurance is very limited. The number of geriatric 

specialists is also very low, further compounding the problem. The care of older people 

with chronic health problems and disabilities is mainly done by family members. 

However, changing family values, rising cost of living and migration into towns and cities 

or abroad has meant that many Kenyans are living away from parents, hence, unable to 

adequately fulfil their traditional role of caring for them – leading to the rise of older 

person’s homes. Most of these homes are run by religious institutions or private 

institutions. A 2016 audit of residential institutions of older persons in selected counties 

in Kenya revealed that there are very few such institutions in the country, none of which 

was run by the government (24). Furthermore, the audit revealed that the existing 

homes lack reliable and predictable means of funding. Generally, although family 

caregivers play an important role in providing physical, emotional, and social support to 

the elderly, they face several challenges including poverty, and lack of knowledge and 

skills to provide effective care. Moreover, although most of the older adults live in large 

multigenerational households, a significant and growing number live alone in isolated 

homesteads. Not long ago (2009), the country enacted a draft policy for older people 

and ageing and subsequently revised it in 2014 and 2019, seeking to recognize, 

empower, and facilitate older people to participate in society, for them to enjoy their 

freedoms and live in dignity. However, its implementation, monitoring, and evaluation is 

lacking (25).  

The above discourse poses difficult questions for many governments, researchers, and 

practitioners, particularly in LMICs like Kenya, which are still struggling to provide basic 

amenities for the general public and cope with the continuing burden of infectious 

diseases and extreme poverty. For instance, how do older adults conceptualize their 

health and wellbeing in different SSA settings? What are the biomedical, psychosocial, 

and environmental determinants of health and wellbeing for the several millions of older 

people in SSA? How can healthcare systems be aligned to meet the complex 



6 
 

healthcare needs of older people? How can research evidence inform the design of 

healthcare systems and other public support programs for the ageing population in 

SSA? Whose responsibility is it to care for older adults, families, or government – 

considering the changing trends of filial piety and intergenerational exchanges in many 

African countries? This PhD seeks to begin to contribute to answering some of these 

pertinent questions, more so in the context of OALWH, one of the fastest growing HIV 

sub-populations worldwide thanks to the widespread use of antiretroviral therapy (ART) 

and increasing HIV infections among older people.  

The following section summarizes and provides a critical analysis of the most recent 

literature regarding the epidemiological characteristics of OALWH, health challenges of 

ageing with HIV, and HIV disease comorbidity with mental, cognitive, and geriatric 

disorders in this population. Several research gaps are identified, leading to the design 

of the current PhD study.   

1.4. Overview of the current HIV burden  

Four decades have elapsed since the first reported cases of acquired immunodeficiency 

syndrome (AIDS) in 1981 (26). Over the years, the world has made tremendous 

progress in ending the HIV/AIDS pandemic, thanks to sustained political leadership, 

international collaborations, extensive funding from bilateral and multilateral sources, 

and the rollout of innovative service delivery approaches. Since 2010, new HIV 

infections have reduced by 38%, while AIDS-associated deaths have declined by 69% 

(27). Despite the remarkable efforts witnessed, the global HIV/AIDS pandemic is far 

from over. According to the Joint United Nations Programme on HIV/AIDS (UNAIDS), 39 

million people were living with HIV/AIDS across the world in 2022: 37.5 million adults 

≥15 years and 1.5 million children, 0-14 years (27). In the same year, 1.3 million people 

became newly infected with HIV and approximately 0.6 million people died from AIDS-

associated complications. Additionally, a recent UNAIDS report showed that the global 

90-90-90 HIV treatment targets (i.e., 90% of people living with HIV – PLWH know their 

status, of whom 90% receive ART, and of whom 90% attain viral suppression by 2020), 

were not achieved (28). Relatedly, the 95%-95%-95% HIV treatment targets (i.e., 95% 

of PLWH know their status, of whom 95% receive ART, and of whom 95% attain viral 



7 
 

suppression by 2025) were negatively impacted by the coronavirus disease (COVID-19) 

(29). Based on statistical models, it has also been estimated that ART interruption 

occasioned by the pandemic could elevate HIV mortality by 10% in endemic settings 

within five years (30).   

As the epidemic enters its 5th decade, SSA continues to bear a disproportionate burden 

of the overall HIV burden, accounting for about two-thirds of the global burden of 

infection (see Figure 1.1 for prevalence estimates). As of 2022, 25.6 million of the 39 

million PLWH – 66% - lived in SSA. Moreover, about 51% of the new HIV infections and 

60% of the AIDS-related deaths registered in 2022 came from SSA (27).  

 

Figure 1.1: HIV prevalence across the world in 2021: Source: Institute for Health Metrics 
and Evaluation (IHME), Global Burden of Disease (2024).  

(https://ourworldindata.org/hiv-aids) 

 



8 
 

1.5. Older adults and HIV 

Amidst the unprecedented ageing of the world's population, is the rapid ageing of the 

HIV population worldwide. Presently, PLWH aged ≥50 years, widely recognized as older 

adults in HIV literature, are among the fastest-growing segments of PLWH across the 

world. Two factors mainly drive the rapid rise in the number of OALWH globally. First, 

improved survival following the introduction of effective combination antiretroviral 

therapy (cART). Second and of concern is the increasing incidence of HIV among older 

adults partly because of their engagement in high-risk sexual behaviour (e.g. multiple 

sexual partners, non-condom use), limited knowledge of HIV risk and prevention, and 

low rates of HIV testing (31-34). In some ways, older people are at a higher risk of HIV 

infection compared to younger people. For instance, in older women, menopause 

causes a natural thinning of the vaginal walls, leading to an elevated risk of internal 

injury during coitus and subsequent exposure to HIV (35). Also, especially in SSA, 

contraception is viewed more as a method to prevent pregnancy than to prevent 

sexually transmitted infections. Post-menopausal women no longer require 

contraception, which may result in a reduction in condom-use. Certain customs such as 

wife inheritance (that elevates vulnerability to non-consensual sex) and ritual cleansing 

(where widows are expected to have sex with family or community members following 

the husband’s death) also increase older women’s risk of exposure to HIV (36, 37). 

There is also some evidence showing that ageing is associated with lower adoption of 

voluntary medical male circumcision (38) – which has been shown to be about 60% 

effective at preventing HIV infection in men (39). 

The UNAIDS first recognized PLWH aged ≥50 years as a special HIV population in its 

2014 Gap Report, alongside 12 other populations regarded to be more at risk of HIV 

infection and poorer HIV treatment outcomes (40). The report cited four key reasons 

why OALWH were being neglected in the HIV care continuum, including low perception 

of HIV risk, complicated management of HIV and other health issues, low access to 

services and stigma and discrimination. Unfortunately, UNAIDS has not put in place any 

plans to specifically address the needs of OALWH apart from the special supplement to 

the UNAIDS report (40). The only mention of older adults in the UNAIDS’s 95-95-95 

strategy is the acknowledgement of accelerated ageing and the multiple comorbidities 



9 
 

OALWH may experience (41). Nonetheless, no direct plans or services are proposed to 

comprehensively mitigate issues specific to this population.  

In 2014, there were approximately 4.2 million OALWH across the world (40). This 

number increased to 5.7 million in 2016, representing 16% of the entire HIV population 

(42). This proportion was modelled to reach 21% in 2020, with Eastern and Southern 

Africa containing the highest number of OALWH worldwide (42). Figure 1.2 highlights 

the changing numbers of OALWH from 2000 to 2020. In High-Income Countries (HICs), 

more than 30% of the PLWH are now aged ≥50 years (42), and this proportion is 

projected to reach 70% by 2035 in certain areas, including the United States of America 

(43) and some parts of Europe (10, 43). Among PLWH in SSA, 15% are aged  ≥50 

years, and this proportion is expected to double by 2040 (44). In East Africa, Kenya has 

an estimated HIV prevalence of 9% (for those aged 50-54 years), 8% (among those 55-

59 years), and 6% (for those aged 60-64 years), compared to the national HIV 

prevalence of 5% (19).  

HIV and ageing is generally an emergent research area in many countries in SSA 

compared to HICs, where its course and implication are better described. Most 

population-based HIV prevalence surveys in SSA have not included older adults, 

limiting the accuracy of prevalence estimates in this age group.  

 



10 
 

 

Figure 1.2. Number of older adults living with HIV who are aged ≥50 years in HICs and 

LMICs, 2000 – 2020. Source: Autenrieth, Christine S., et al  

"Global and regional trends of people living with HIV aged 50 and over: Estimates and 

projections for 2000–2020." PloS one 13.11 (2018): e0207005. 

(https://doi.org/10.1371/journal.pone.0207005.g003) 

 

1.6. The challenges of living with HIV as an older adult  

People living with HIV, in general, face a myriad of challenges that may compromise 

their long-term health. These challenges include the burden of managing a life-long 

diagnosis (with strict adherence to ART medications, regular medical check-ups, and 

treatment of opportunistic infections), special dietary considerations in addition to the 

health uncertainties surrounding the condition (e.g., due to social stigmas, and unstable 

viral loads). Others include psychosocial challenges. Reports exploring the lived 

experiences of PLWH in different parts of the world have documented several 

psychosocial challenges: including difficulties in accepting HIV-positive status, HIV 

disclosure fears, ART adherence obstacles, social isolation, and HIV-related stigma and 

discrimination (45-48). In many SSA countries like Kenya, inadequate resources further 

complicate the living situation of PLWH. Not surprisingly, socioeconomic challenges 

https://doi.org/10.1371/journal.pone.0207005.g003


11 
 

such as financial difficulties, prolonged cycles of poverty, food insecurity, and caregiving 

burden have been identified as some of the additional concerns experienced by PLWH 

in the region (46, 49-51).  

For OALWH, there are several other considerations, even though many of the issues 

highlighted above also apply to older individuals. Older adults living with HIV face 

unique challenges compared to their younger counterparts. Many healthcare 

professionals and the general public believe that older adults have a lower risk of HIV 

infection. A fairly recent study from SSA analyzed data from demographic and health 

surveys of 10 SSA countries, documenting the covariates of high-risk sexual behaviour 

among men aged ≥50 years (52). Findings indicated that 74% of men were sexually 

active, and a significant proportion of the men regularly engaged in unsafe sexual 

behaviours, including multiple sexual partners and unprotected sex. The covariates of 

high-risk sexual behaviour included older age, urban residence, and having primary or 

secondary education. The presumption that older adults are not sexually active or drug 

users creates obstacles to early HIV testing and access to preventive health information 

for these adults. Consequently, a significant proportion of OALWH (nearly 50%) get 

diagnosed late in the course of their disease, i.e., CD4 cell counts below 350 cells per 

microliter or the presence of an AIDS-defining event (53). This is concerning because 

delayed presentation for HIV treatment reduces OALWH ability to benefit from early 

ART initiation and also prolongs the period in which they may expose others to infection. 

Additionally, research evidence (mainly from European cohorts of HIV and ageing) 

shows that older people are more likely than younger people to have multiple health 

conditions which complicate their care and treatment, e.g., neurocognitive impairment, 

elevated levels of polypharmacy (8, 10, 54). OALWH also have elevated levels of 

multimorbidity compared with individuals of similar age without HIV (10). Alongside late 

HIV diagnosis and multimorbidity, OALWH also experience an intersection of HIV-

related and age-related stigma (ageism), a crucial challenge for attaining long-term 

health and healthy longevity (55).  

Generally speaking, there are two distinct groups of OALWH: those who were 

diagnosed before the age of 50 years and have been living with HIV and taking ART for 



12 
 

a longer time (sometimes referred to as long-term survivors), and those who were 

diagnosed in their old age. Evidence from HICs shows that many of the long-term 

survivors (from the pre-ART era) continue to be impacted by the legacy of the early 

years of the epidemic, including multiple HIV-related bereavements, “survivor guilt”, 

post-traumatic stress disorder, living for many years with an uncertain diagnosis, 

financial insecurity, lack of caregivers and historical and ongoing stigma and 

discrimination (56-58). These adults have also had to contend with the long-term toxicity 

of ART regimens (59). Some of the common comorbidities associated with long-term 

ART use and chronic HIV infection include renal and metabolic disease, fractures, 

osteoporosis, central nervous system disorders, cardiovascular and liver diseases (59).  

As it stands, most healthcare systems, especially LMICs, are ill-equipped to address the 

unique needs of the rising population of OALWH.   

In SSA, where the vast majority of OALWH live, there have been a few studies exploring 

the health challenges these older adults face (60-70). From these studies, the 

challenges that OALWH face are similar to those highlighted above (delayed diagnosis 

and care seeking, difficulty disclosing or non-disclosure, double burden of stigma, 

suboptimal ART adherence, financial burden, and food insecurity). Additional challenges 

include multiple healthcare appointments (as services are not integrated), poor patient-

provider communication, attitudes and behaviours, inadequate quality facilities, 

inadequate training or limited knowledge for healthcare providers, shortage of staff 

(leading to long queues), unemployment, and end-of-life concerns. Within the SSA 

region, the mental, cognitive, and functional health experience of OALWH has barely 

been investigated using qualitative studies, highlighting a vital research gap to better 

understand the experiences and needs of OALWH in the region.  

1.7. HIV, mental, cognitive, and geriatric disorders: an overview of the 

comorbidity 

 

The advent of ART more than 20 years ago has successfully changed the management 

of HIV/AIDS from a life-threatening disease to a manageable chronic condition akin to 

diabetes and hypertension (71-73). Effective use of cART has led to significant gains in 



13 
 

the fight against the HIV epidemic, including reduced HIV-related morbidity and mortality 

(74, 75) and extended longevity (76). As of the end of 2022, 29.8 of the 39 million PLWH 

were on cART, representing 76% of ART coverage globally (27). Similar trends are 

being experienced in SSA, with a steady rise in ART coverage. More than three-

quarters (81%) of PLWH in the region were on HIV treatment by the end of 2022 (27). In 

Kenya, this proportion was significantly higher (94%) during the same period (27). Given 

these achievements, the focus is now shifting towards understanding HIV-associated 

comorbidities and their long-term impacts on health and wellbeing (10).  

Neuropsychiatric disorders and geriatric syndromes are some of the most important 

comorbidities in PLWH, including OALWH (77-81). Of the neuropsychiatric disorders 

comorbid with HIV, common mental disorders - CMDs (e.g. depression and anxiety 

disorder), and neurocognitive impairments are most prevalent (79, 80, 82). It is 

challenging to estimate the precise burden of CMD comorbid with HIV in different 

contexts due to variations in measurement tools or diagnostic criteria, lack of a suitable 

comparison group and differences in contextual factors (83). In a fairly recent global 

systematic review and meta-analysis (84), the pooled prevalence of depression was 

found to be 31% among adults living with HIV but with a very high heterogeneity index 

(98%). In terms of geographical location, the prevalence of depression among adults 

living with HIV was highest in South America (44%) and lowest in Europe (22%). In 

another global metanalysis by Rahmati, J., et al. (2021), the pooled prevalence of 

anxiety among PLWH was found to be 25%, but with a significant level of heterogeneity 

of 98%. By geographical region, the prevalence of anxiety was lowest in Africa at 19% 

and highest in South America at 38%. Within SSA, studies examining CMDs in PLWH 

are not as extensive as those from HICs in North America and Europe. However, this 

narrative is slowly changing as more contextually appropriate measures of CMDs are 

being adapted or developed for use in these settings, thus laying the foundation for 

more research (85-89). Reviews documenting the prevalence of CMDs among adults 

living with HIV in SSA have registered prevalence estimates of over 30%, particularly for 

depressive symptoms (87, 90). For anxiety, prevalence is as high as 19% among adults 

living with HIV (91) and 46% among young PLWH in SSA (92). Anxiety disorders have 

received much less scientific and clinical attention compared to depressive disorders. 



14 
 

From a public health standpoint, the lack of research in this area is alarming because 

anxiety disorders are likely to be very prevalent and have a significant detrimental effect 

on functioning.  

HIV-associated neurocognitive impairment (HAND) is also a common comorbidity 

among PLWH (79, 80). Evidence shows that PLWH have higher levels of cognitive 

impairment compared to their uninfected peers (93). Similar to CMDs, the accurate 

burden of HAND in PLWH is highly variable, depending on the measurement tools, 

diagnostic criteria, study design, geographical area, and respondents' ART status (80, 

94-97). In a global review of the literature on HAND in PLWH (80), a pooled prevalence 

of 50% was reported. In this review, HAND prevalence estimates were comparable in 

HICs and LMICs. Within SSA, however, the prevalence of HAND was found to be highly 

variable in a recent systematic review (95), ranging from 14% to 88%, and a pooled 

prevalence of 46%. 

One of the most striking consequences of the ageing process in HIV infection is the 

development of geriatric syndromes (such as sarcopenia, frailty, and falls), multifactorial 

conditions resulting from deficits in several domains, including psychological, clinical 

and environmental vulnerabilities (81, 98). Studies primarily carried out in HICs have 

revealed a high prevalence of geriatric syndromes in OALWH, as well as an early 

incidence of these conditions (99). Frailty, one of the most common geriatric syndromes, 

is frequently characterized by a decline in physiological capacity in multiple organ 

systems, resulting in intensified vulnerability to stressors (100). In a recent systematic 

review, the overall pooled prevalence of frailty and prefrailty was 11% and 47%, 

respectively, but with a high degree of heterogeneity (93%) (101). The next section 

provides an overview of the burden and underlying factors of these outcomes but with a 

focus on OALWH.  

1.8. HIV, mental, cognitive, and geriatric disorders among OALWH: burden and 

associated factors 

Common mental disorders (e.g., depression and anxiety), HAND, and geriatric 

syndromes (frailty) are also evident among OALWH. Many of these conditions co-exist 

and account for a significant burden of years lived with disability among older adults 



15 
 

(102, 103). The known risk factors for these conditions, e.g., loneliness, HIV-related 

stigma, ageism, caregiving burden, multimorbidity and poor health-seeking behaviours, 

are significantly elevated among OALWH (104, 105). The prognosis of these conditions 

appears worse among OALWH (106). Despite this, these conditions are often 

overlooked, undetected, under-researched, and not treated in line with appropriate 

guidelines (103). Anxiety disorders and geriatric syndromes have received much less 

attention compared to depression and HAND; thus, their aetiology, manifestation and 

management are poorly understood.  

The extant literature on the burden and determinants of these conditions among 

OALWH is mainly based on studies carried out in HICs. Only one global systematic 

review (107) has attempted to summarize the prevalence of depression among OALWH. 

In this review, the authors reported a pooled prevalence of depression of 28% but with a 

high heterogeneity index of 95%. In the same review, the prevalence estimates of 

depression ranged from 15% in the Netherlands to 42% in  South Africa. To the best of 

my knowledge, no review has summarized the global burden of anxiety among OALWH. 

However, among the few available empirical studies, prevalence estimates range from 

36% (108) to 65% (109). Relatedly, no review has systematically summarized the 

factors associated with both depression and anxiety among OALWH globally. Among 

the existing empirical studies, social capital (108, 110), physical exercise (111), 

resilience (112), being employed (113), and higher income (113) have been documented 

as important correlates of reduced CMDs while smaller social networks (111, 114), HIV-

related stigma (114-116), loneliness (115), poor perceived health status (111), food 

insecurity (117), older age (≥70 years) (113), rural residency (113), and other 

comorbidities (118) have been shown to be important predictors of elevated CMDs 

among OALWH.  

To the best of my knowledge, no global meta-analysis has exclusively reviewed the 

burden of HAND among OALWH. Wang et. al summarized the global prevalence of 

HAND among adults aged ≥18 years in 2020, but also provided age-disaggregated 

prevalence estimates, including that of ≥50 years which was reported to be 42.5%(119) . 

Evidence from existing empirical studies, largely from European cohorts, report HAND 



16 
 

prevalence estimates as high as 50% (8, 120, 121). Notably, the pooled prevalence of 

HAND is shown to vary widely across settings and populations partly because of the 

assessment and diagnostic criteria used. The HAND criteria, also referred to as Frascati 

criteria, is the most common criteria of assessment around the world. Although it has 

been successful in providing a consistent pattern of classification in global research 

efforts, it has been associated with overestimating the burden of cognitive impairment, 

given the drastic changes of HIV disease in the era of potent ART (122). New 

approaches have been thus recommended (94).  

Among existing studies, factors associated with an elevated risk of HAND include a 

history of low nadir CD4 (120, 123), older age (124), lower educational level (123-125), 

comorbidities such as diabetes, frailty, stress, depression (123, 126), lack of social 

support (126, 127), and stigma (127). A global meta-analysis of 21 studies examining 

the association between HIV infection and cognitive impairment reported that OALWH 

were more likely to be cognitively impaired than their uninfected counterparts (Odds 

Ratio – (OR) = 2.4), especially for studies from HICs, e.g. the US and Europe but not in 

upper-middle-income countries such as Southeast Asian countries and South Africa 

(93). Moreover, OALWH presented with lower scores than uninfected adults in five out 

of seven major cognitive domains, including processing speed, verbal, 

motor/psychomotor, executive function, and recall. Recently, Spooner et al. examined 

the longitudinal prevalence of HAND among 253 OALWH over three years in what is 

arguably the first longitudinal follow-up of a cART-treated cohort of OALWH in SSA 

(124). Forty-seven percent of the cohort met HAND criteria at baseline.  

Two meta-analyses have summarized the global burden of frailty among OALWH. The 

first one (128) reported a varied prevalence of frailty ranging from 5% to 29%, 

depending on the population studied. The second review (101) reported a pooled 

prevalence of frailty of 11% as defined by the Fried frailty phenotype. Factors 

associated with elevated frailty, as reported in one of the two reviews (128), included 

older age, lower educational attainment, unemployment, low income, comorbid 

conditions (psychiatric disease, cognitive impairment, chronic kidney disease, diabetes 

mellitus and low body mass index), low current and possibly nadir CD4+ cell count.  



17 
 

We have systematically reviewed the published literature on the burden and 

determinants of depression, anxiety, cognitive function, and frailty among OALWH aged 

≥50 years residing in SSA (129). The review included 44 studies (26 on depression, 13 

on cognitive function, 3 on frailty and 2 on anxiety) conducted across 15 SSA countries, 

mainly from Ethiopia, South Africa, and Uganda (about two-thirds of the studies). Since 

the publication of our systematic review in 2021, three new studies (2 on depression 

and 1 on frailty) have been published (130-132). Our review found wide-ranging 

prevalence estimates for depression (6% to 59%), anxiety (3% to 21%), cognitive 

impairment (4% to 61%) and frailty (3% to 15%) among OALWH. Only a handful of the 

included studies were carried out exclusively among older adults ≥50 years. Our review 

noted several methodological concerns, including a high risk of bias (about 40% of the 

included studies), small sample sizes, unrepresentative samples, and failure to report 

tool reliability and validity. Some of the outcomes, e.g., cognitive impairment, were 

documented in multiple ways, e.g., HAND, dementia, and cognitive dysfunction, thus 

making it difficult to quantify and compare across studies. Moreover, a good number of 

the included studies had overlapping age groups for their comparison groups, e.g., 18 to 

50, 18-54, 18-55), thus making it difficult to compare their outcomes with those of older 

adults ≥50 years. The correlates of CMDs, frailty and cognitive impairment were rarely 

investigated in the articles included in our review. The frequently reported correlates 

were largely sociodemographic factors. Female sex was more consistently associated 

with poorer outcomes. Relatedly, low socioeconomic indicators e.g. low income, 

unemployment, and food insecurity were more consistently associated with poor mental 

and cognitive health outcomes.  

1.9. Adverse outcomes of HIV comorbid with mental disorders or geriatric 

syndromes 

An extensive corpus of HIV literature has shown that the co-occurrence of HIV with 

mental morbidities (both CMDs and cognitive impairments) and geriatric syndromes is 

associated with deleterious health outcomes across the HIV care continuum thus 

affecting HIV management and its overall prognosis in all populations of PLWH, 

including older adults (133, 134).  Some of the detrimental outcomes of these 

comorbidities on the health and wellbeing of PLWH include increased proclivity for risky 



18 
 

sexual behaviours such as multiple sexual partners and non-condom use (135, 136), 

reduced health-seeking behaviours, poor quality of life (133), reduced economic 

productivity and increased risk for suicidality (133). Frailty, one of the commonest 

geriatric syndromes, has been associated with disability (137), dementia (138), 

premature mortality (139), and emergency hospital admissions among older adults 

(140). 

Research has also demonstrated that mental morbidities among PLWH are associated 

with HIV-specific negative outcomes such as faster disease progression and 

subsequent mortality (141), virologic and immunologic failures (134), suboptimal 

adherence to ART (142, 143), and the onset of drug-resistant HIV strains (144, 145).  

1.10. Existing research gaps and study justification 

Sub-Saharan Africa has the youngest population in the world, yet it is ageing rapidly. 

The population of older adults aged ≥50 years in the region is projected to triple by 2050 

from the current estimates of 117 million (15). With a myriad of competing needs, issues 

of older adults are given limited attention, let alone prioritized. Although many countries 

in SSA have formulated policies on healthy ageing, not much has been achieved with 

the implementation of the existing policies, especially on mental, cognitive and 

functional health, which appears to have been completely neglected (21). Amidst this 

demographic shift is also the rapid ageing of the HIV population in the region, which has 

produced a subgroup of vulnerable older adults (42). While the course and effects of 

ageing in the context of HIV are well documented in HICs, HIV and ageing in most SSA 

countries, including Kenya, is an emergent area of research. Consequently, little is 

known about the health and wellbeing of OALWH in the region, and any programs and 

policies regarding their wellbeing have been made on the basis of limited evidence. 

Data from HICs may not be readily generalized to inform policies and programs in SSA 

given the differences in the profile of OALWH, e.g., with respect to age, sex, identity, 

race and ethnicity, sexual orientation, and socioeconomic status. For instance, in the US 

alone, over three-quarters of the OALWH are males and most of them (about two-thirds) 

were infected through male-to-male sexual contacts, and a significant proportion of the 

OALWH are long-term survivors (started living with HIV before effective ART became 



19 
 

available); this compared to the population of OALWH in SSA where most OALWH are 

heterosexuals, slightly more women than men, and most are in their early 50s and 60s 

(105). These differences and others, including burden and contextual factors, healthcare 

systems, and formal and informal support systems, call for local data to inform 

meaningful progress and policy in the prevention, identification, and management of the 

complex needs of OALWH.  

Much of what is known about HIV and ageing in SSA is predicated on quantitative 

studies. This data is essential and much needed; nonetheless, it does not capture the 

lived experience of ageing with HIV. The utility of qualitative enquiries to highlight the 

lived experiences of OALWH will provide a rich, holistic account of how these individuals 

perceive their lives and adjust to their age-associated complications and psychosocial 

modifications as they age with HIV. This is especially critical within SSA, where most of 

the healthcare systems are unprepared to meet the needs of OALWH and older adults 

in general. Studies exploring the challenges that OALWH face are currently few in many 

sub-Saharan African countries, including Kenya. More of these studies are needed to 

provide a more comprehensive understanding of how the OALWH create meaning 

around HIV in their lives and how they cope with daily health challenges. This is even 

more important in SSA as new cohorts of HIV and ageing are emerging for the first time 

and, given the variability in some of the current findings (129). 

Research on the prevalence and factors associated with CMDs among OALWH are 

limited, and most of the existing studies are concentrated in Uganda, South Africa and 

Ethiopia (129). Virtually all the existing research on CMDs among OALWH in the region 

has focused on depression rather than anxiety (129). Besides, the correlates of CMDs 

in OALWH are not well established. Few studies have examined the correlates of 

CMDs, and most of those examined are sociodemographic, the majority of which are 

inconsistent across studies (129). Because of these reasons, further research is 

urgently needed in the region to enhance our understanding of the burden and 

determinants of CMDs among OALWH. Strikingly, among the existing studies on 

depression/depressive symptoms, there appears to be a growing body of studies 

showing lower prevalence estimates for CMDs among OALWH than their uninfected 



20 
 

peers (129). This finding offers an interesting contrast to the commonly reported findings 

from HICs which point to a higher burden of depression among OALWH compared to 

their uninfected counterparts. The mechanisms responsible for these observations are 

not well established and require further research in the region, as the findings are based 

on a limited number of studies.  

Studies documenting the prevalence and correlates of HIV-associated cognitive 

impairment among OALWH are similarly limited in the SSA region partly because of 

limited HAND screening and diagnostic tools (129). Although HAND screening is 

recommended in routine HIV care to allow for early interventions, it is rarely done in 

SSA partly because of the lack of contextually relevant screening tools. Most of the 

existing tools have inadequate psychometric properties, and very few have been 

adapted and validated for use among OALWH (146). It is imperative that more HAND 

tools are validated for the growing population of OALWH to generate accurate 

prevalence estimates, enable domain-specific understanding of HAND and allow early 

opportunities for intervention. One such tool that has shown promise is the Oxford 

Cognitive Screen Plus (OCSPlus) tool, a brief, tablet-based, domain-specific cognitive 

assessment tool designed for low-literacy settings (147). OCSPlus was an 

advancement of an initial tool – Oxford cognitive screen (OCS), to detect subtle 

cognitive changes in older adults. OCSPlus is a free and easy to use tool developed by 

the Translational Neuropsychology Research Group at the University of Oxford. Unlike 

many conventional tests, which rely on reading and numeracy skills, the OCSPlus relies 

more on visual abilities, with literacy and numeracy are not required to complete the 

test, thus more relevant for the population of older adults in SSA, where a significant 

number have low literacy levels (148, 149). In SSA, OCSPlus has only been validated 

among adults from the HAALSI cohort in South Africa (147). The initial validation in 

South Africa among adults aged 40-79 years indicated that the tool had excellent 

construct and external validity. Outside SSA, OCSPlus has been validated among 

neurologically healthy older adults from a pooled English and German normative 

sample , the results also showing the validity and reliability of the tool (149). The tool 

has been standardized, normed and validated in healthy ageing in HICs. More 



21 
 

validation data is needed for the OCSPlus tool in the region e.g. reliability, and 

acceptability among different populations of older adults e.g. OALWH. 

Studies on frailty among OALWH are generally few across the globe. In SSA, these 

studies are particularly limited. Only three studies, from Tanzania, South Africa and 

Ethiopia, have reported prevalence estimates among OALWH (129, 132). Thus, the 

burden and factors associated with frailty among OALWH in SSA are grossly 

understudied and inconclusive, highlighting the urgent need for more studies to 

understand this construct in the region properly.  

This PhD thesis provides initial data to help us understand the mental, cognitive, and 

functional health needs of OALWH in the SSA setting, specifically on the Kenyan coast. 

To begin with, this work explores the perceptions of OALWH, primary caregivers and 

healthcare providers to understand the health challenges of ageing with HIV and the 

coping strategies used by OALWH to confront these challenges. Subsequently, this 

work documents the prevalence and factors associated with CMDs and frailty. Further to 

this, I also provide preliminary evidence on the reliability and validity of the OCSPlus 

measure and document the cognitive performance and associated factors among 

OALWH in the study setting. No study in Kenya has examined the burden and 

determinants of CMDs, frailty and cognitive function among OALWH. Several HIV 

studies (among PLWH) have documented poorer psychosocial, mental, and physical 

health than their HIV-uninfected peers in the study setting. Unfortunately, it is unclear 

whether the patterns observed in the younger PLWH are similar or different among 

OALWH in the same study setting. Anecdotal reports from many HIV clinics in the study 

setting suggest an increasing number of OALWH and concurrent unmet healthcare 

needs for this population. So as to have a comprehensive understanding of the 

aforementioned outcomes among OALWH in this setting, I adopt a broader approach 

utilizing diverse research methodologies. The following section contains a description of 

the current PhD study. The various PhD sub-studies are described in detail in the 

subsequent chapters of this thesis.  

 

 



22 
 

1.11. Current study  

The research gaps identified in the previous sections are addressed in the studies 

presented in this thesis. The remainder of this chapter describe the study objectives, 

design, setting, data sources and the overall thesis outline. Further methodological 

details will be provided for each PhD study in the subsequent chapters. 

1.11.1 Study objectives  

The studies reported in this thesis were carried out in two phases: Phase I and Phase II, 

each with distinct objectives. The overarching objective of the first phase was to 

understand the health situation of OALWH (challenges and coping strategies) on the 

Kenyan coast. The phase I dataset generated two manuscripts (Chapters 2 and 3 of the 

thesis respectively). For phase II, the overall objective was to document the burden and 

associated factors of CMDs and frailty and also highlight the neurocognitive profile of 

OALWH on the Kenyan coast. The phase II dataset generated three manuscripts 

(Chapters 4, 5 and 6 respectively).  

The specific objectives included:  

Phase I specific objectives:  

a) To explore the biopsychosocial health challenges faced by OALWH (≥50 years) 

from the Kenyan coast.  

b) To explore the coping strategies and support systems used by OALWH (≥50 

years) to improve their mental health and wellbeing from the Kenyan coast. 

 

Phase II specific objectives 

c) To determine the prevalence and factors associated with depressive and anxiety 

symptoms among OALWH (≥50 years) from the Kenyan coast compared to their 

HIV-uninfected counterparts.  

d) To determine the prevalence and factors associated with frailty among OALWH 

(≥50 years)  from the Kenyan coast compared to their HIV-uninfected 

counterparts.  



23 
 

e) To examine the acceptability, reliability, and validity of a local (Swahili) measure 

of neurocognitive function, the Oxford Cognitive Screen Plus (OCSPlus), among 

OALWH (≥50 years) and their HIV-uninfected peers and provide an initial 

understanding of the cognitive performance of these adults (by HIV status) and 

the biopsychosocial factors associated with their cognitive performance.    

 

1.11.2 Study design  

I utilized a mixed methods research design to achieve the stated research objectives, 

employing both qualitative and quantitative research methodologies. The primary 

purpose of utilizing mixed methods was to provide a better and deeper understanding, 

by providing a fuller picture that enhances description and understanding of the health 

and wellbeing of older adults in the study setting. The qualitative component was 

essential in contextualizing the issues of HIV and ageing in the study setting (as no 

other study has been reported from the Kenyan coast previously), seeking to build a 

greater understanding of the individual, family, healthcare providers, and broader socio-

cultural and economic factors that may influence the quantitative outcomes (CMDs, 

frailty and neurocognitive performance).  

1.11.3 Study setting  

The studies reported in this thesis were carried out at the coastal region of Kenya, in 

Kilifi and Mombasa counties, through the Centre for Geographic Medicine Research – 

Coast. Kenya is an Eastern African country bordering the Indian Ocean (to the 

Southeast) with an area of about 580,000 square kilometres. Kenya’s immediate 

neighbours are Uganda (to the West), Ethiopia (to the North), Somalia (to the East), 

South Sudan (to the Northwest) and Tanzania (to the Southwest). The country is divided 

into 47 devolved units of government (counties) with a total population of  47,564,296, 

of which 23,548,056 (49.5%) are males (17). The country has the fifth-largest number of 

people living with HIV worldwide, with 1.3 million PLWH in 2018 (150). Estimates from 

national population-based surveys and sentinel surveillance show that the national HIV 

prevalence peaked at about 11% in the mid-1990s and reduced to around 6% in 2006 

(151, 152). Prevalence estimates have remained relatively stable at that level for many 



24 
 

years, with a reduction witnessed from 2010 to 2017 (153). In 2018, the countrywide 

prevalence was estimated at 4.9%, twice as high in women (6.6%) compared to men 

(3.1%) (150). The epidemic is geographically diverse in the country, with prevalence 

estimates ranging from 21% in Western Kenya (Siaya County) to a low of 0.1% in the 

Noth-East region (Wajir County) (153). Prevalence estimates for older adults ≥50 years 

are limited in the country. Major sources of statistics typically only present data for men 

and women aged 15 and 49 years and selected groups of older adults, e.g., those aged 

50-54, 55-59, and 60-64 years. Recent reports indicate that HIV prevalence is 9.2% (for 

those aged 50-54 years), 7.5% (for those aged 55-59 years) and 5.9% (for those aged 

60-64 years) (150). Anecdotal reports also indicate an influx of older adults seeking HIV 

care services in HIV-specialized clinics. HIV care in the country is usually free, but care 

for other medical conditions is harder to access; as such, families and other social 

contacts are important sources of support for the overall health and psychological needs 

of OALWH.  

Kilifi County, one of the six counties in the coastal region of Kenya, has a land area of 

about 12,540 square kilometres and borders the Indian Ocean (to the east), Taita Taveta 

County (to the west), Kwale County (to the Southwest), Mombasa county (to the south) 

and Tana River county (to the north). Kilifi County is predominantly a rural setting (about 

60%) with a population of about 1.5 million people (17), and among the poorest counties 

in Kenya (154) with low literacy levels, high rates of school dropout and teenage 

pregnancy (155, 156). Subsistence farming and local home businesses are the primary 

sources of livelihood. The HIV prevalence for adults ≥15 years in Kilifi is estimated at 

4.5%, with women more disproportionately more affected (157). The HIV prevalence 

estimate for older people ≥50 years is unknown in this setting as it is not routinely 

documented during surveys. However, anecdotal reports from several HIV clinics in the 

study setting suggest an increasing number of older PLWH with unmet healthcare 

needs.  

Mombasa County, with a land area of about 220 square kilometres, borders Kilifi County 

(to the north), Indian Ocean (to the east) and Kwale County (to the Southwest). It is 

primarily an urban setting with an estimated population of 1.2 million (17). The common 



25 
 

sources of income in Mombasa include tourism, wholesale, and retail trade. The 

Mombasa adult HIV prevalence is estimated at 7.5% (157). Figure 1.3 presents the 

map of Mombasa and Kilifi counties and surrounding catchment areas where the 

recruitment of participants for this PhD was conducted.  

 

Figure 1.3. A map of Mombasa and Kilifi counties and study recruitment sites 

1.11.4 Sources of data 

The aforementioned specific objectives were implemented utilizing data from sampling 

of different study participants (as highlighted in Table 1.1).  

Phase I, specific objectives 1 & 2 

To explore the biopsychosocial health challenges that OALWH aged ≥50 years 

experience and the coping strategies for enhancing their mental health and wellbeing, 

in-depth interviews were conducted with 34 OALWH, 11 healthcare providers and 11 

primary caregivers in an empirical qualitative study carried out at the CGMR-C in Kilifi 



26 
 

county. Semi-structured interview guides were used during the interviews, and all 

interviews were audio-recorded. Chapters 2 and 3 detail the results of Phase 1, which 

were published as two separate qualitative peer-reviewed articles. Further 

methodological details of the studies are provided in the respective chapters.  

Phase II, specific objectives 3, 4 and 5 

To investigate the CMDs, frailty (burden and associated factors) and neurocognitive 

profile of OALWH on the Kenyan coast, I designed a cross-sectional study, collected, 

and analyzed data from 440 older adults aged ≥50 years (257 adults living with HIV). 

Table 1.1 summarizes the research methodologies utilized in the study. In this specific 

study, a set of sociodemographic, psychosocial and outcome measures (depression, 

anxiety, frailty, and cognitive function) alongside clinical and health or lifestyle history 

forms were collected from the respondents and data recorded in the Research Data 

Capture (REDCap) platform on Android tablets (158).  Chapters 4, 5 and 6 detail the 

results of Phase II, which are presented as separate quantitative articles. Further 

methodological details of the studies are provided in the respective chapters. 

1.11.5 Outline of the subsequent portions of the thesis  

Chapter Two is a qualitative inquiry exploring the perceptions of adults living with HIV 

(≥50 years), healthcare providers and primary caregivers on the health challenges of 

ageing with HIV. The biopsychosocial model of health is applied for this exploration. 

Chapter Three presents the results of a qualitative study exploring the strategies for 

improving mental health and wellbeing used by adults with HIV aged ≥50 years from the 

Kenyan coast. Chapter Four is an empirical descriptive cross-sectional study measuring 

the prevalence and associated factors of depressive and anxiety symptoms in OALWH 

compared to their HIV-uninfected peers on the Kenyan coast. Chapter Five presents the 

findings of an empirical cross-sectional study, measuring the prevalence and factors 

associated with frailty among OALWH compared to their HIV-uninfected peers. Chapter 

Six of the thesis presents the findings of an empirical descriptive cross-sectional study 

seeking to examine the acceptability, reliability, and validity of a local (Swahili) version of 

the OCSPlus measure among older adults aged ≥50 years. Also, it describes the 

cognitive performance of these adults (by HIV status) and the biopsychosocial factors 



27 
 

associated with their cognitive performance. Finally, Chapter Seven provides a general 

discussion of the thesis, integrating the findings from the various research studies 

reported in this thesis. Additionally, the chapter discusses the methodological limitations 

of the different studies and highlights the implications of the study in terms of future 

research, policy, and clinical practice.   

 



 

28 
 

Table 1.1. A highlight of the sources of data, applied measures and primary outcomes in the different thesis 

chapters 

Chapter Objective of the study Type of study  Sample description  Measurement tools Primary outcomes 

Two 

(159) 

To explore the biopsychosocial 

health challenges faced by 

OALWH (≥50 years) from the 

Kenyan coast 

Qualitative inquiry  - 34 adults ageing with 

HIV (≥50 years), 11 

healthcare providers 

and 11 primary 

caregivers  

- Purposive sampling to 

maximize participants 

characteristics  

- Participants were 

recruited from the 

specialized HIV clinic of 

the Kilifi County 

Referral Hospital (KCH) 

Pre-tested semi-

structured interview 

schedule 

- Physical health 

challenges  

- Mental health 

challenges  

- Psychosocial health 

challenges  

Three 

(160) 

To explore the coping strategies 

and support systems used by 

OALWH to improve their mental 

health and wellbeing from the 

Kenyan coast 

Qualitative inquiry  Coping strategies and 

support systems for 

enhancing the mental health 

and wellbeing of OALWH  

Four 

(161) 

To determine the prevalence and 

factors associated with CMDs 

among OALWH (≥50 years) from 

the Kenyan coast compared to 

their HIV-uninfected counterparts 

Quantitative 

cross-sectional 

study  

- 440 older adults aged at 

least 50 years (257 

living with HIV and 183 

without HIV) 

- OALWH were 

systematically recruited 

from two public HIV 

specialized clinics, one 

- Sociodemographic, 

clinical, 

health/lifestyle 

forms 

- Psychosocial 

measures (stigma, 

ageism, loneliness)  

- PHQ-9 and GAD-7 

Common mental problems:  

o Anxiety symptoms  

o Depressive 

symptoms  

o Comorbid anxiety 

and depressive 

symptoms  



 

29 
 

Five 

(162) 

To determine the prevalence and 

factors associated with frailty 

among OALWH (≥50 years)  from 

the Kenyan coast compared to 

their HIV-uninfected counterparts 

Quantitative 

cross-sectional 

study 

in Kilifi (KCH) and one 

in Mombasa (Coast 

General Teaching and 

Referral Hospital)  

- HIV-uninfected older 

adults were randomly 

identified using the Kilifi 

Health and 

Demographic 

Surveillance System 

(KHDSS) database and 

followed up at their 

homes for recruitment 

using Global Positioning 

System (GPS) 

coordinates.  

- Sociodemographic, 

clinical, 

health/lifestyle 

forms 

- Psychosocial 

measures (stigma, 

ageism, loneliness) 

- Reported 

Edmonton Frail 

Scale 

 

Frailty  

Six  To examine the acceptability, 

reliability, and validity of a local 

(Swahili) measure of 

neurocognitive function, the 

Oxford Cognitive Screen Plus 

(OCSPlus), among OALWH and 

their HIV-uninfected peers and 

provide an initial understanding of 

the cognitive performance of 

these adults (by HIV status) and 

the biopsychosocial factors 

associated with their cognitive 

performance 

Quantitative 

cross-sectional 

study 

- Sociodemographic, 

clinical, 

health/lifestyle 

forms 

- Psychosocial 

measures (stigma, 

ageism, loneliness) 

- OCSPlus  

- Ravens standard 

progressive 

matrices  

- International HIV 

dementia scale  

 

- Acceptability of Swahili 

OCSPlus 

- Internal consistency of 

Swahili OCSPlus  

- Test-retest of Swahili 

OCSPlus  

- Convergent validity of 

Swahili OCSPlus  

- Cognitive performance 

profile 



 

30 
 

 

 

Chapter 2 
 

 

 

 

 

Navigating life with HIV as an older adult on the Kenyan 

coast: perceived health challenges seen through the 

biopsychosocial model 
 

 

 

 

 

Patrick N. Mwangala, Ryan G. Wagner, Charles R. Newton, and 

Amina Abubakar 

 

 

Published in 

International Journal of Public Health (Ageing and Health In Sub-

Saharan Africa Special Issue). 2023 June 15; 68:1605916. doi: 

10.3389/ijph.2023.1605916 

 

 

 



 

31 
 

2.0 Background to Chapter 2 

This thesis has so far summarised the existing evidence on HIV and ageing, pointing 

out the epidemiological characteristics of OALWH and the unique health challenges 

they face in SSA, thus laying a foundation for the empirical research conducted for this 

PhD. This chapter provides site specific insights of the health and wellbeing of OALWH 

at the Kenyan coast. The overall qualitative study was divided into two clear objectives 

and sub-analyses and published separately. The current chapter addresses the first 

objective which was to explore the health challenges faced by OALWH at Kilifi, a low 

literacy setting at the coast of Kenya. The second objective, which was to explore the 

coping strategies used by the OALWH to improve their mental health and wellbeing, is 

presented in the next thesis chapter, Chapter 3.  

 

2.1 Abstract 

Background: Kenya, like many sub-Saharan African countries (SSA), is experiencing a 

rise in the number of HIV-infected adults aged ≥50 years (recognized as older adults 

living with HIV. Unfortunately, there is a paucity of data on the challenges faced by this 

emergent population of OALWH. This study explores the perceptions of OALWH and 

their primary caregivers and healthcare providers on the health challenges of ageing 

with HIV at Kilifi, a low literacy setting on the coast of Kenya.    

Methods: We utilized the biopsychosocial model to explore views from 34 OALWH and 

22 stakeholders on the physical, mental, and psychosocial health challenges of ageing 

with HIV in Kilifi in 2019. Data were drawn from semi-structured in-depth interviews, 

which were audio-recorded and transcribed. A framework approach was used to 

synthesize the data.  

Results: Symptoms of common mental disorders, comorbidities, somatic symptoms, 

financial difficulties, stigma, and discrimination were viewed as common. There was 

also an overlap of perceived risk factors across the physical, mental, and psychosocial 

health domains, including family conflicts and poverty.  



 

32 
 

Conclusion: OALWH at the Kenyan coast are perceived to be at risk of multiple 

physical, mental, and psychosocial challenges. Future research should quantify the 

burden of these challenges and examine the resources available to these adults.  

 

Keywords: Older adults, HIV, Kenya, biopsychosocial challenges  

2.2 Introduction  

The last decade has witnessed a dramatic shift in the demographic profile of people 

living with human immunodeficiency virus (HIV) globally. Presently, many HIV clinics are 

caring for a growing number of adults aged ≥50 years (categorized as older adults) due 

to increased survival in people living with HIV (PLWH) and a steady rise in HIV 

diagnoses in this age cohort (42). More than 30% of the PLWH in High-Income 

Countries (HICs) are now aged ≥50 years (42) compared to 15% in sub-Saharan Africa 

(SSA) (44). These statistics herald a new era in the HIV epidemic response, where the 

needs and demands of the OALWH can no longer be ignored, especially in Eastern and 

Southern Africa, home to more than half the number of OALWH globally (42).  

Research findings, mainly from HICs, indicate that OALWH present with an average of 

three comorbid conditions in addition to HIV, including medical diseases (e.g., diabetes, 

hypertension), mental health problems (e.g., depression, anxiety, substance use, 

cognitive problems) and social challenges (e.g., stigma, loneliness, and lack of social 

support) (129, 163-165). The observed mental health challenges reduce the quality of 

life of these adults and have important health implications, e.g., poor HIV treatment 

(166). The physical health problems faced by OALWH may also be complicated by 

environmental and psychosocial challenges such as poverty, food insecurity and lack of 

support (166).  

Despite the evidence of complex health challenges related to ageing and HIV, little 

research has qualitatively examined how OALWH understand their health and care 

needs. To date, most studies of ageing and HIV in SSA are cross-sectional studies 

focusing on biomedical processes and outcomes and rarely provide local insight into the 

health and wellbeing of these adults (167). Qualitative studies are needed to better 



 

33 
 

understand the experiences and needs of this diverse population, especially among 

low-literacy populations. This is especially important as many cohorts of OALWH  are 

emerging for the first time across the SSA region, and the apparent variability in findings 

among previous studies, e.g. in the prevalence and determinants of chronic 

comorbidities (167). Apart from complementing quantitative studies in accurately 

documenting the burden and determinants of the health challenges in these adults, 

qualitative studies will shed light on the contextual factors to guide the development or 

adaptation and subsequent implementation of culturally appropriate interventions in this 

population. Overall, the few qualitative studies among OALWH in SSA are mainly 

concentrated in Uganda (60-63, 168) and South Africa (64-66, 169, 170). Others are 

from Kenya, Eswatini and Malawi (68, 171-173). In Uganda, ageing with HIV is seen as 

a daily challenge financially and socially (60-63,