Introducing the behavioral preventive treatment program in panel C of Figure 3-2 has little impact because most of the transmission is happening at much younger ages, which do not impact the total number of adults age 50 and older during the comparatively short period of 10 years over which the treatment is applied. The existing HIV-positive population at the time the treatment started continues to die as it did over the 10 years of the treatment, thereby continuing to create the orphans that contribute to the percentage of adults age 50 and over who have surviving grandchildren but no surviving children.

In contrast, the antiretroviral treatment program has an immediate and very positive impact on this indicator, panel D of Figure 3-2. The number of adults age 50 and older stabilizes because HIV-related adult mortality is deferred, and the number of adults age 50 and older with surviving grandchildren but no surviving children also stabilizes for the same reason. The net result is a stabilization of the percentage of adults age 50 and older with surviving grandchildren but no surviving children at a level of about 9 percent for women and 4 percent for men.

The combined treatment program (panel E) produces a result almost identical to the antiretroviral program—as expected given the fact that the behavioral preventive program had little effect.

HIV-mediated changes in the number and percentage of adults age 50 and older who are in a position to be required to care for young children are very significant and display a strong sex differential. By the time a vigorous HIV epidemic stabilizes, up to one-quarter of women age 50 and older may have surviving orphaned grandchildren for whom they must care, while up to 15 percent of older men may be in the same position. The 40 years simulated here are not sufficient to see these indices stabilize; they are still rising steadily in year 40. Given the 20- to 25-year lag between the time HIV is introduced to the population and the beginning of the rise in this indicator, the future is ominous for those who will be age 50 and older in sub-Saharan Africa over the next 10 to 15 years.

Taken as a whole, the findings presented here paint a nuanced picture of the impact of HIV on a population, and in particular of the consequences for older people. Results obtained in the course of this work but not presented here indicate that through subtle changes in the age structure, driven by changes in both fertility and mortality, the dependency ratio is likely to fall and that furthermore the decline is largely driven by changes in the male age structure. Additional big changes are wrought on the age structure, resulting in a stable age structure with a “stepped” shape after the epidemic has stabilized that is likely to be younger than the pre-HIV age structure.

Front Matter (R1-R12)

Executive Summary (1-6)

Part I: Report -- 1. Aging in Sub-Saharan Africa: Recommendations for Furthering Research (7-45)

References (46-52)

Part II: Papers -- 2. Aging in Sub-Saharan Africa: The Changing Demography of the Region (53-91)

3. Demographic Impacts of the HIV Epidemic and Consequences of Population-wide Treatment of HIV for the Elderly: Results from Microsimulation (92-116)

4. The HIV/AIDS Epidemic, Kin Relations, Living Arrangements, and the Elderly in South Africa. (117-165)

5. Older Adults and the Health Transition in Agincourt, Rural South Africa: New Understanding, Growing Complexity (166-188)

6. The Situation of Older People in Poor Urban Settings: The Case of Nairobi, Kenya (189-213)

7. Labor Force Withdrawal of the Elderly in South Africa (214-249)

8. HIV/AIDS and Older People in South Africa (250-275)

9. Interactions Between Socioeconomic Status and Living Arrangements in Predicting Gender-Specific Health Status Among the Elderly in Cameroon (276-313)

10. Survey Measures of Health: How well do Self-Reported and Observed Indicators Measure Health and Predict Mortality? (314-342)

Appendix A Workshop Agenda (343-350)

Appendix B About the Contributors (351-356)