The overarching aims of IeDEA-SA are to conduct clinical, epidemiological and health services research in order to provide answers to the questions that clinicians, programs and ministries of health consider fundamental to HIV care and treatment strategies in Southern Africa; to inform HIV/AIDS, TB, cancer and mental health service delivery in the region, to increase the capacity for delivering antiretroviral therapy (ART), and, ultimately, to improve the prognosis of people living with HIV and AIDS in Southern Africa.
As the region with the greatest number of HIV+ adults and children and a sizable co-morbidity burden, the scientific agenda responds to the operational and clinical research priorities identified by the World Health Organization (WHO) and opinion leaders in the field and focuses on questions that cannot be answered by one cohort. IeDEA-SA’s potential is widely recognized by information consumers, including WHO and UNAIDS, and the HIV Modelling and MESH consortia. IeDEA-SA is also leading in innovations, from novel approaches to statistical modelling to linkages with other records including national death and cancer registries.
The specific aims of IeDEA-SA are i. to study the continuum of adult HIV care including ART from diagnosis to outcomes ii: to study co-infections and cardiovascular and metabolic co-morbidities iii: to study the burden and care of cancers in HIV + children and adults iv: to study the care continuum in HIV+ mothers and their children, from pregnancy to exposed uninfected infants through to infected infants, children and adolescents v: to study mental health and mental health care provision vi: to study substance use in adolescents and adults on ART vii: to use and develop state-of-the-art methods and standards to facilitate multi-regional analyses.
I completed my Statistics honours degree in 2016 at the University Of KwaZulu-Natal with a project titled ‘Modelling survival time data’, in which I reviewed the basic concepts of survival analysis and assessed the factors affecting the survival of patients. I am currently enrolled at the University of Cape Town, working towards my master’s dissertation. I wish to assess the effect of delay in treatment switching in HIV infected South African adults.
Ernest Mokotoane is from the Free-State province, he has a BSc degree in Information Technology from University of the Free-State. He has been working with health information since 2012, has experience working with databases and data management. He joined IeDEA in November 2017 as Data Manager for South Africa.
Tshabakwane (Tshabs) Nembandona is a Senior Data Manager for the IeDEA-SA data centre. He has over a decade of experience in Information Technology specialising in database management, security, backups, database development and administration, and data management.
Tshabs is pursuing a PhD in Information Systems at the University of Cape Town, and his research interests include mobile technology and bullying in South African schools, mobile security, and digital forensics. He offers data management and support, collaborating with other data managers from IeDEA regions including participating in the IeDEA data harmonization working group.
Gem is an epidemiologist at the UCT Data Center, currently focusing on research related to pediatric HIV. She has a Masters in Epidemiology from the London School of Hygiene and Tropical Medicine, an interest in infectious diseases, and has worked as a field epidemiologist primarily doing operational research to address specific challenges in the delivery of primary care to those with HIV.
Mmamapudi completed her MPH in 2016, her thesis sought to understand the epidemiology of diabetes in a high tuberculosis and HIV context Khayelitsha, South Africa. She was also involved in a study that determined the association between TB and diabetes. (odds ratio 2.4; 95% confidence interval 1.3–4.3) in a study population with high HIV prevalence (64%) (1). Building on her MPH work, she is currently working on her PhD project that seeks to understand the effect of diabetes, HIV and household overcrowded living conditions on the South African TB epidemic. She will develop an individual-based model to represent TB dynamics in South Africa. The model will be used to: a) understand and explain the observed gender and age differences in TB; b) assess how effective current TB control interventions have been in reducing TB incidence in South Africa up to the current time c) determine the population attributable burden of tuberculosis due to HIV, diabetes, and household overcrowded living conditions; and d) evaluate the potential impact of current TB control interventions that target to reduce HIV, diabetes and household overcrowding in addition to current TB control interventions
Victoria completed her MPH (Epidemiology) degree in 2016 at the University of Cape Town. Her thesis was titled “Prevalence and determinants of unplanned pregnancy in HIV-positive and HIV-negative pregnant women in Cape Town, South Africa: a cross-sectional study” She described the importance of preventing unplanned pregnancies among HIV-positive women as one of the crucial tools for the prevention of mother-to-child transmission of HIV (PMTCT) in high burden, resource-limited settings such as South Africa. The study presented key differences between HIV-positive and HIV-negative women regarding pregnancy intentions and family planning practices. Younger age (<24 years old), increasing parity and contraceptive use in the year prior to conception were associated with an increased probability of an unplanned pregnancy. The manuscript was published in BMJ Open (Iyun et al. 2018).
Victoria is currently working on her PhD project at the University of Cape Town. Her PhD is focused on understanding the effect of expanded early infant diagnosis (EID) and early infant antiretroviral therapy (EIART) guidelines and practices, on patient and program-level outcomes among HIV-infected infants and young children in resource-limited settings.
Priscilla recently completed her Master’s in Public Health (Epidemiology) degree at the University of Cape Town. Her thesis was titled: “HIV viral load monitoring in HIV-infected pregnant women established on antiretroviral therapy in Cape Town, South Africa”. The literature review discussed the role of HIV viral load and antiretroviral therapy (ART) on vertical transmission of HIV and compared the existing ART monitoring strategies and management of viremia in resource-limited settings. She described public sector HIV viral load testing patterns (frequency and timing) and HIV viral load levels for pregnant women conceiving on ART, before and during pregnancy. In addition, the analysis assessed factors associated with having a HIV viral load (VL) test performed and being viremic during pregnancy. Defining viremia as a VL >1000 copies/mL, the analysis concluded that 80% of women had VL tests done during pregnancy, and of these approximately 88% had VL.
Priscilla is currently working as a Research Officer and has just begun her PhD at the University of Cape Town. Her PhD will focus on the models of care and the models of transition to adult HIV services for HIV-infected adolescents within Southern Africa.
Kati is a gynecologist by training and has completed her Fellowship with the Royal Australian and New Zealand College of Obstetricians and Gynecologists. She has learned greatly from diverse clinical experiences in New Zealand, USA, Italy, Switzerland, Ethiopia, and Iran. Cervical cancer screening has been a research interest of hers for some time. The burden of cervical cancer disproportionately affects women living in low-income countries and the high prevalence of HIV in many of these setting contributes to the problem. She joins the ISPM IeDEA-SA team in 2017 to work towards a PhD focused on cervical cancer screening in HIV positive women.
Anthony is a PhD student working on HIV drug resistance (DR) in Sub-Saharan Africa at ISPM in Bern. He joined the IeDEA team in February 2017, after having completed studies in applied mathematics. More specifically, the aim of his project is to develop a mathematical model in order to study evolution over time of both acquired and transmitted drug resistance (ADR and TDR respectively). The model will also be able to assess the effectiveness of different kinds of treatments/interventions in order to curb the spread of DR.
Olivia joined the ISPM in November 2006 to work on her PhD in epidemiology, using data from ART-LINC and the IeDEA collaboration. The focus of her PhD was analysis of treatment outcomes according to individual and program characteristics. During her PhD she spent time in Lilongwe, Malawi and South Africa working with collaborating sites and attending several courses. During this time she became increasingly independent, taking the lead in writing grant applications and scientific publications, presenting work at national and international conferences and supervising others. Olivia successfully defended her PhD (“The clinical and public health epidemiology of combination antiretroviral therapy in low-income settings: collaborative analyses of cohort studies”) in November 2009. Since April 2011 Olivia heads the research group ‘HIV and Hepatitis’ at the ISPM. This research group is concerned with the clinical and public health epidemiology of HIV/AIDS and with co-infections with hepatitis C. The main focus is on long term outcomes of ART, mother-to-child transmission of HIV in Malawi and the development of mathematical simulation models in the field of HIV and hepatitis C.
Andrew was co-Principal Investigator of IeDEA-SA from its inception until 2011. During this time, he completed his PhD on the effectiveness of ART in Khayelitsha and in the Western Cape, following adults for up to five years on ART and examining temporal trends over seven years, during a time when ART services expanded dramatically in the province. Andrew explored associations with a range of clinical outcomes, and regimen durability and tolerability are described, together with regimen effectiveness when ART is administered to patients co-infected with TB. The results chapters are in the form of published/submitted papers [1, 2, 3, 4, 5] covering: correction for under-ascertainment of mortality through linkages with the death registry; the tolerability of commonly-used first-line ART; the effectiveness of ART co-administered with TB treatment; an in-depth description of the Khayelitsha population demonstrating comparability with many urban settings in the region; and evidence that outcomes have not been compromised by the expansion of ART services. The thesis concludes that the analyses provide reassurance that the anticipated benefits of ART have not been eroded by health system weaknesses or contextual challenges.
Lucy’s MSc in Statistics thesis analyzed time to ART initiation, exploring the effect of factors that predict how soon a patient initiates ART and the causal effect of ART initiation on the survival of patients. She used observational data on patients co-infected with HIV/TB from three clinics in the Western Cape. Using observational data presents a number of statistical challenges: measurements on patients are not always recorded within time intervals of interest, nor are they always recorded regularly; treatment of patients is not assigned at random, so that patients who have a worse prognosis a-priori will initiate ART sooner than those who have a better prognosis, which could bias the estimated effect of ART initiation on survival. Lucy therefore used methods to reduce potential biases, as well as to explore the sensitivity of assumptions that she makes where possible.
Janne’s PhD thesis consisted of mathematical modelling studies comparing the potential benefit and cost-effectiveness of routine viral load monitoring of ART in sub-Saharan Africa. The main task was to develop a mathematical model for disease progression of HIV under ART. The model was used to compare the potential transmission from patients on ART with or without routine viral load monitoring, and to explore if the large observed differences in mortality between IeDEA-SA sites with and without viral load monitoring could be attributed to the monitoring strategy. The cost-effectiveness of viral load, CD4 and clinical monitoring were also compared. The results showed that routine viral load monitoring is very likely a cost-effective intervention, but mainly due to its indirect benefits, such as the ability to detect poor adherence and prevent treatment failures. Routine viral load monitoring is also expected to prevent about one third of HIV transmissions caused by treated patients. The PhD project included also other collaborative studies: a statistical analysis of first-year mortality and loss to follow-up in the entire Malawian national ART database, and three systematic reviews of pre-ART retention among adults, children, and pregnant women. Janne Estill continues to work at the ISPM as a postdoctoral researcher. He develops mathematical models and cost-effectiveness analyses for the disease progression and transmission for HIV, viral hepatitis and other infections, focusing in particular on the different patient management strategies of ART for HIV infected adults and children in sub-Saharan Africa.
Mary-Ann has been co-Principal Investigator of IeDEA-SA since 2011. Her PhD thesis was entitled ‘Outcomes and effectiveness of antiretroviral therapy for HIV-infected children in South African treatment cohorts’. The thesis reviewed the outcomes of published studies of pediatric ART cohorts in Africa, described outcomes for children receiving ART in South Africa and examined determinants of mortality and generalizability across Southern Africa. Temporal trends in characteristics at ART were also examined. The measurement of treatment success in resource-limited settings was reviewed by examining virological failure and assessing the diagnostic accuracy of immunological criteria for identifying virological failure. The results chapters were presented in the form of published/submitted papers based on data from IeDEA-SA [1, 2, 3, 4, 5, 6, 7] . The thesis concluded that access to ART for children had increased, with good outcomes. HIV cohort research is important in evaluating the safety and effectiveness of different models of care, treatment and monitoring strategies.
Laetitia’s MPH thesis determined the probability of and reasons for stopping/changing of antiretroviral drugs in South African pediatric sites of IeDEA-SA. The study population included all HIV infected children ≤16 years of age at ART initiation with a documented date of birth and initial regimen of ≥3 antiretroviral (ARV) drugs, and attending any one of 7 South African pediatric HIV clinic sites that contribute data to the IeDEA-SA database. Data from 5517 children with median [IQR] age at ART start of 42 [15-82] months were included in the analysis. By 3 years on ART, 81% of children alive and in care were still taking their initial regimen. Drug stops/changes for reasons other than treatment failure were mainly due to potential drug interaction in the 1st year on therapy, while in the 3rd year toxicity, potential drug interaction, treatment simplification (e.g. changing from syrup to tablet formulations) and other unspecified reasons were the main contributors. Nevirapine, zidovudine and stavudine were responsible for most treatment-limiting toxicity by 2 years on ART. Nevirapine toxicity occurred almost entirely in the first six months whereas stavudine toxicity occurred mostly after 1 year of therapy. Half of the zidovudine toxicity occurred in the first 3 months with the remainder evenly spread over the following 21 months. Laetitia concluded that pediatric ART durability in resource-limited settings was good but complex, with treatment changes due to toxicity, treatment failure and drug interactions, as well as treatment simplification. After completing her MPH, Leatitia worked with the Infectious Diseases Research Collaboration in Uganda as a study coordinator of an implementation science project called STARTs (Streamlined ART Initiation Strategy study), which was aimed at starting as many HIV-infected adults on ART as possible once they were eligible by CD4 count. Leatitia is currently doing an MMED in Pediatrics and Child Health at Makerere University in Uganda.
Mireille completed her MPH at the UCT in the epidemiology/biostatistics stream. Her thesis was entitled: “Outcomes of Infants Starting Antiretroviral Therapy in Southern Africa, 2004–2012” and included an extensive literature review and a manuscript prepared for publication. The literature review confirmed that there was limited published data on the outcomes of infants starting ART in routine care in Southern Africa. Subsequently she conducted an analysis of prospectively collected routine cohort data contributed from sites to IeDEA-SA. The manuscript described the demographic, baseline disease and therapeutic characteristics of just under 5000 infants at initiation of treatment and describes outcomes relating to growth, disease progression, programmatic outcomes and mortality. The analysis further assessed those baseline factors associated with treatment failure (virological) and mortality. The study described severe baseline disease severity, suboptimal responses to ART and high loss-to-follow up in infants starting ART in Southern Africa between 2004-2012. Severe baseline disease characteristics and initiation of ART before 2010 were associated with an increased probability of death. The manuscript was published in JAIDS (Porter, Davies et al. 2015). Mireille is currently acting as a Clinical and Research Consultant in a project to produce a Health Promotion Tool for Primary Health Care for the National Department of Health South Africa.
Morna has project managed the IeDEA-SA Data Center at UCT since January 2007. In 2008, she completed her MPH thesis based on data from one IeDEA-SA cohort. In 2014 she was awarded a PhD for her thesis ‘The evolution and effectiveness of the South African antiretroviral therapy programme’. Her thesis presented five inter-related analyses using data from South African sites within IeDEA-SA in the form of published/submitted papers. The studies included anonymized, patient-level data on adults starting ART to describe patient characteristics and enrolment, and to explore program outcomes including mortality, loss to follow-up and transfers out, as well as chapters focusing on the impact of gender and age on program outcomes. The numbers of patients included in the analyses ranged from 19 481 (restricted to cohorts with South African national identification numbers) to 83 592 adults, followed for up to 168 789 person-years of observation. The results of the thesis lead to novel conclusions regarding the major challenges to ART program effectiveness in South Africa. While early ART programs were concerned primarily with patient mortality, increasingly the central challenges facing these services are related to their implementation and coverage. Looking forward, the South African national ART program should deliver services to patients earlier in the course of HIV disease, focusing in particular on men and patients over 50 years of age. Additional interventions are required to promote the retention of patients in lifelong chronic care while maintaining effective systems for program monitoring.
Luisa recently finished her PhD in Biomedical Sciences at the ISPM where she has been since 2011. The topic of her thesis was mathematical modelling in HIV and Hepatitis C. She used mathematical models to simulate disease progression and estimate the impact of public health interventions on health outcomes. Her projects included the development of an individual based model of pediatric HIV to estimate the impact of different strategies to monitor children on antiretroviral therapy; and a hepatitis C virus transmission model to evaluate the effect of behavioural and treatment interventions on the spread of this virus among HIV-positive men who have sex with men. Previously, Luisa studied physics with a focus on theoretical physics and applied mathematics specializing in numeric methods at the National University of Colombia in Bogotá. Luisa is very interested in mathematical modelling of infectious diseases and Monte Carlo simulations of dynamic systems in nature. Currently, Luisa is working at the ISPM on mathematical modelling and molecular epidemiology of hepatitis C virus transmission among people living with HIV.
Eliane, who is a medical doctor, has been working at the ISPM in public health since 2012. She completed her MSc in Epidemiology at the London School of Hygiene and Tropical Medicine (LSHTM) by distance learning. Her research focus is HIV-related cancer and oncogenic viruses and her MSc thesis examined the incidence rate of invasive cervical cancer (ICC) in a South African cohort of HIV-positive women. In a meta-analysis, she examined the association between HIV and human herpesvirus 8 (HHV-8), the infectious cause of Kaposi sarcoma (KS). This meta-analysis showed that HIV-positive persons were more likely to be seropositive for HHV-8 than HIV-negative persons. Another research project focused on the incidence rate of KS and associated risk factors in HIV-positive children and adults participating in IeDEA-SA. She is also working on multiregional IeDEA projects to estimate and compare ICC and KS incidence rates in HIV-positive persons across different continents.
Kirsten’s MPH thesis addressed the challenge of adherence to lifelong cART whilst maintaining future regimen options for vertically infected children. This study evaluated a simplification strategy – substituting efavirenz for lopinavir-ritonavir (LPV/r) in children older than 3 years maintaining virologic suppression, thereby allowing for a once-a-day regimen and for re-use of LPV/r later on. In this cohort of children exposed to no more than a single dose of nevirapine as infant prophylaxis, the virologic outcomes in the EFV substitution group were no worse than those of children remaining on their initial LPV/r-based regimen. Kirsten has run the ARV services at the public sector New Somerset Hospital since 2010. She is about to embark on a new journey in community and family medicine, with part-time research work at UCT.
Erna’s MPH thesis addressed one of the IeDEA-SA objectives, namely to establish and describe a sub-cohort of HIV-infected pregnant women and their exposed infants. The protocol included background information on sites contributing to this cohort of HIV-exposed uninfected (HEU) infants. The literature review included maternal disease factors, the use of antiretroviral therapy and the association between feeding modality and growth, focusing on studies conducted on the African continent. The manuscript detailed the methodology, results and interpretation of longitudinal analysis of growth among HEU infants in IeDEA-SA. This cohort of HEU infants included 2621 infants from two South African sites. The median birth WAZ was -0.65 (IQR -1.46; 0.0), 51% were male and there was a median of 2 visits per infant. The feeding modalities practiced were: 0.5% exclusive breastfeeding, 7.9% unknown breastfeeding exclusivity, 78.6% mixed breastfeeding and 10.6% formula feeding. Mothers with a CD4 <200 cells/μl delivered infants with a lower birth WAZ (adjusted ß -0.253 [95% CI -0.043; -0.072], p = 0.006) compared to mothers with a CD4 ≥500 cells/≧l. Similarly, mothers who did not receive antiretroviral (ARVs) drugs delivered infants with a lower birth WAZ (adjusted ß -0.49 [95% CI -0.78; -0.20], p = 0.001) compared to mothers who received antenatal ARVs. Antenatal maternal ARVs and CD4 cell count did not have an effect on postnatal growth. Mixed effects models using maximum likelihood estimation for the longitudinal analysis of growth showed that exposure to breast milk positively influenced growth, albeit the effect was small. Overall, less severe maternal disease and the use of ARVs positively impacted birth weight. Mixed feeding was common, and any breastfeeding may have a positive effect on longitudinal growth. Since 2014, Erna has been working for the Western Cape Department of Health within the Health Impact Assessment Directorate, Epidemiology and Disease Surveillance sub-directorate.
The aim of Mazvita ‘s thesis was to characterize the epidemiology of HIV-related cancers in South Africa in terms of spectrum, prevalence and incidence of cancers in HIV-positive individuals in the era of antiretroviral treatment in South Africa. This was achieved through 3 studies: (i) a probabilistic record linkage study of two IeDEA-SA ART programs providing care for adults and the National Cancer Registry in South Africa, (ii) a cross-sectional analysis of HIV testing patterns among black adult cancer patients attending a tertiary academic oncology unit in Johannesburg and (iii) a chart review of patients with AIDS-Kaposi sarcoma attending a tertiary academic oncology unit in Pretoria. She found that ascertainment of cancer in HIV cohorts is incomplete, and probabilistic record linkage is both feasible and essential for cancer ascertainment. The prevalence of cancer among HIV patients was 4%. Incidence of cancer in HIV-positive South Africans in the era of potent ART was high (overall incidence rate of 1,315/100,000 pys (95% CI 1,225-1,410)), particularly for AIDS-defining cancers and infection-related cancers. She recommended a systematic approach to cancer surveillance in HIV-positive people and the exploration and implementation of known cancer-specific prevention strategies in the HIV population. Among black adult cancer patients in Johannesburg, 33.7% tested positive for HIV; and over a third of those who were positive were unaware of their HIV status. She therefore recommended routine opt-out HIV testing for cancer patients. Among AIDS-KS patients in Pretoria, survival has improved in recent years as more patients access appropriate ART, chemotherapy and radiation therapy. Mazvita currently works as the project manager and epidemiologist for the South African HIV Cancer Match Study, which is an IeDEA-SA supported national HIV-cancer record linkage study, at the National Cancer Registry, National Health Laboratory Service.
Lyson’s PhD project aims at identifying the programmatic issues that can impede the attainment of Prevention of Mother to Child Transmission (PMTCT) of HIV potential benefits in resource limited settings like Malawi. Using routine health records collected during antenatal, delivery, ART and exposed child follow-up, his project aims at identifying factors that determine uptake and retention along the PMTCT care cascade. The health records are drawn from 19 large health facilities in the central and southern Malawi. Lyson’s first analysis was based on the ART data and it aimed at assessing factors associated with retention in care for women in the ART program after the adoption of the Option B+ approach in Malawi. He found that 17% (n-219239) were lost at six months with most of the loss occurring in the first 3 months. Compared to women who started ART for their own health, pregnant women who started ART because of their pregnancy status were more likely (OR 5.0, 95% CI 4.2-6.1) not to come for a follow-up visit after starting ART, followed by those who started while breast feeding (OR 2.2, 95% CI 1.8-2.8). Loss to follow up was therefore found to be highest among pregnant women who started ART on the same day they were diagnosed HIV positive and those treated in large clinics. A second analysis was based on the antenatal clinic (ANC) data. The analysis aimed at assessing HIV status ascertainment and its predictors during pregnancy. In this analysis he found that there was suboptimal HIV testing levels in the country at 82.3% (95% CI 80.2-85.9%) compared to the elimination of mother to child transmission (EMTCT) goal of 90%. He further found that HIV ascertainment was independently associated with higher age and attending an ANC more than once. He further observed high variability of HIV ascertainment between sites ranging from 50.6-97.7% and over time suggesting that HIV test kits shortages and insufficient numbers of staff were the major barriers to reducing MTCT. Currently Lyson is coordinating the Umoyo+ Project, a research collaboration between the ISPM and the HIV and AIDS Department of the MoH in Malawi.
In 2011, the Malawian Ministry of Health developed a pragmatic public health approach to improve the low antiretroviral coverage among pregnant women in Malawi and implemented the “Option B+” protocol. Option B+ provides universal lifelong antiretroviral therapy (ART) for all HIV-infected pregnant and breastfeeding women, regardless of CD4 cell count and/or WHO clinical stage. Following the national implementation of Option B+ the antiretroviral coverage among pregnant women in Malawi increased from 49% in 2011 to 85% in 2014 and numerous countries have adopted the Option B+ policy. After completing a Master’s degree in Sociology at Goldsmiths, University of London Andreas joined the ISPM in 2012, where he completed a PhD in Epidemiology. His PhD project evaluated the effectiveness of Malawi’s “Option B+” and specifically the project identified challenges to program success, and incorporated plans to carry out appropriate interventions.
Using data from IeDEA-SA cohorts, Cleophas’s PhD work will focus on antiretroviral drug resistance among patients failing protease inhibitor-based second-line treatment. HIV drug susceptibility for each participant will be predicted using the Stanford algorithm and will be categorized as susceptible, low level resistance, intermediate resistance, or high level resistance Furthermore, he will assess the factors associated with drug resistance mutations at second-line failure. He will evaluate early treatment response to third-line treatment focusing mainly on viral, immunological and clinical outcomes. Outcomes will be assessed at 24, 48 and 96 weeks post third-line commencement. He will assess the cost effectiveness of third-line treatment by extending our existing simulation model to compare different strategies after second-line ART failure similar to a previous modelling study done by Ouattara et al. Cleophas currently works as a Medical Officer at Newlands Clinic in Harare, Zimbabwe. Newlands Clinic is a private, not for profit organization run by Swiss AIDS Care International-Zimbabwe. The Clinic works in partnership with the Zimbabwe Ministry of Health and Child Care to provide comprehensive HIV treatment and Care to the vulnerable members of society at no cost to the patient.
In developing countries, 9% of the population is now older than 60. In 2050 this will double to 19%. In sub-Saharan Africa (SSA), the HIV-positive population is also aging. Even if the number of people covered by ART is estimated conservatively, there will be 9 million people over 50 living with HIV by 2040. However, if treatment coverage expands at its current rate, this number will rise. Despite the amount of attention received by the HIV epidemic in SSA, there is little information about HIV infection among older adults, or on the burden of HIV and disease outcomes among the elderly in low-income settings. Catrina’s goal is to improve our understanding of HIV among the elderly in SSA by evaluating access to treatment and therapy outcomes in elderly HIV patients in Malawi, and comparing these outcomes to those of younger patients. Currently, she is working as a PhD student at the ISPM, focusing on elderly people, NCDs and HIV in the context of resource limited settings.