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Introduction
The HIV/AIDS epidemic is changing demographic and household structures in sub-Saharan Africa. 1 The effect of the disease on child mortality, 2 life expectancy, 3 and dependent children is well established. The Joint United Nations Programme on HIV/AIDS (UNAIDS) estimated that by 2007, HIV/AIDS had orphaned more than 12 million children in sub-Saharan Africa. 4 However, the toll of the epidemic on Africa's elderly population is poorly characterised.
Despite the epidemic's effects, the number of adults over the age 60 in Africa is projected to rise by 55% between 2010 and 2025, a 135% increase since 1995. 5 6 These changes will increase the dependency ratio and the demand for old age support. In parallel to this demographic transition, however, the HIV/AIDS epidemic is decreasing the supply of family caregivers. Unlike many other diseases, HIV/AIDS causes deaths primarily among working age adults, 7 8 who often serve as primary caregivers for dependent elderly family members. 9 10
In middle income and high income countries, the informal caregiving burden associated with longer lifespans has historically generated political pressure for governments to create old age security programmes. With a few exceptions, formal arrangements for elderly care do not yet exist in sub-Saharan Africa. Instead, family members continue to play a vital role in supporting aging kin. 11 12
In this paper, we quantitatively assessed the extent to which HIV/AIDS is responsible for diminishing support and increasing isolation among older individuals in sub-Saharan Africa. This phenomenon has been described qualitatively and analysed in a few select countries using demographic simulation methods. 13 14 15 16 We analysed nationally representative household survey data from a large number of African countries to examine the relation between the HIV/AIDS epidemic and household support structures for elderly individuals in sub-Saharan Africa.
Methods
Study population and data
Our data on the characteristics of the elderly population and on living arrangements came from the Demographic and Health Surveys conducted by Macro International, Calverton, MD. These surveys are nationally representative household level surveys of many low income and middle income countries and are performed approximately once every five years. The standard survey includes questions about household composition and living arrangements such as age, relationship to head of household, education, and marital status of each...