Left behind? A longitudinal analysis of need for preexposure prophylaxis services among middle-aged and older adults in South Africa.

Introduction: Despite 1.3 million cumulative preexposure prophylaxis (PrEP) initiations in South Africa, 150 000+ people newly acquire HIV every year. A significant proportion of these are middle-aged adults, a population not previously prioritized for PrEP. Evidence on how many middle-aged and older adults in South Africa may benefit from PrEP services is needed.

Methods: We estimate the need for PrEP counseling in a sample of 40+ year-old, rural South Africans in 2018 and 2022, using "Health and Aging in Africa: A Longitudinal Study in South Africa (HAALSI)" data. We first identify potential PrEP eligibility based on a negative HIV status and a body weight of 35+ kg. Within this sample, we define the population that should be counselled on PrEP as per South African Guidelines for the Provision of PrEP based on a recent history of having had sex without a condom. We estimate cross-sectional and longitudinal need for PrEP counseling at the pooled level and disaggregated by sex and age.

Results: Of the 1654 individuals considered potentially eligible for PrEP in 2022, 39.6% overall, 55.7% of men, 26.7% of women, and 63.3% of 40-49 year-olds should be counseled on PrEP. Longitudinally, 29.9 and 22.9% should be counseled on PrEP in both waves or only one wave respectively. Further, we found significantly higher odds of need for PrEP counseling in male, younger, and married individuals.

Conclusion: We find a high need for PrEP counseling among middle-aged and older South Africans, calling for greater attention to HIV prevention, including targeted PrEP for these age groups.