In 2025, an estimated 11.5-million (29%) people living with HIV were aged 50 years and older. This is projected to increase to 20.2-million by 2040. That would account for more than half (51%) of all people living with HIV. And, crucially, 96% will live in low- and middle-income countries. Sub-Saharan Africa is continuing to shoulder the greatest burden of the global HIV epidemic.

Much of this change reflects the success of antiretroviral therapy (ART), which has enabled-millions of people who acquired HIV earlier in life to grow older. The challenge has gone beyond helping people live longer, to ensuring they age well – that they maintain good health, independence and quality of life throughout older age.

Older adults are also acquiring HIV and being diagnosed later in life. But prevention and testing campaigns remain focused on younger people.

Older adults are often assumed to be at low risk because of the misconception that they are no longer sexually active. Healthcare workers may be less likely to discuss sexual health, recommend testing or offer prevention options such as PrEP. Moreover, older people may not see themselves reflected in HIV messaging that’s directed to younger people. These assumptions contribute not only to delayed diagnosis and treatment, but also to discrimination within healthcare, where opportunities for prevention and early detection may be missed.

African context

Our recent Lancet Healthy Longevity study, using data from the Africa Wits-Indepth Partnership for Genomic Research (AWI-Gen), provides an important longitudinal (long-term) African perspective that reinforces the Lancet Commission’s message. We analysed data from more than 7 000 adults 40 years and older in Kenya and South Africa, including rural and urban populations. The data was collected in 2013-2016 and 2019-2022. Data like this helps us examine what is changing over time: whether treatment outcomes are improving, and which groups remain overlooked.

Our findings also show that older adults are not one uniform population. HIV risk was shaped by gender, education, socioeconomic circumstances and place.

Widowed women had the highest HIV prevalence, at 30.8%. This may reflect economic insecurity and persistent gender inequalities that continue to influence HIV vulnerability later in life. Prevention must respond to these gendered and social realities.

Stigma and ageism compound the problem. The perception that HIV is a disease of younger people can make diagnosis in later life feel especially shameful. Older adults may delay testing or avoid discussing their sexual health because they do not perceive themselves – or are not perceived by others – as being at risk. This can affect testing, disclosure, mental health and continued engagement with care.

Comorbidity

The Lancet Commission supports our findings that the population over 50 is more likely to receive a delayed HIV diagnosis, and calls for tailored HIV prevention and screening for this age group. It further recognises the need for thoughtful screening and management of age-related comorbidity. In addition it calls for the integration of HIV services with health services provided to the general public.

A distinctive strength of our work is that we do not study HIV in isolation.

Through the long-term research undertaken be the MRC/Wits Agincourt unit and AWI-Gen, we have spent years examining ageing and health in African populations. Our longitudinal data allow us to consider HIV alongside hypertension, diabetes, obesity and other chronic conditions, and to investigate how these conditions accumulate and interact as people age.

A person may be taking ART with medicines for hypertension and diabetes while also coping with reduced mobility, depression or financial insecurity. Several individually appropriate treatment guidelines can become unmanageable when applied to the same person. Care must consider physiological rather than chronological age (what’s happening to a person’s body, not just how old they are in years), functional ability (what they are still able to do), polypharmacy (being on multiple medications) and what matters to the individual.

Health systems must also adapt to these new circumstances where more people are living with different chronic (long-term) conditions. An older person should not have to attend separate clinics and make repeated journeys. This is particularly burdensome in rural areas. HIV, chronic disease and healthy-ageing services need to be brought closer together, with HIV testing available through chronic disease services and HIV care routinely addressing noncommunicable diseases and mental health.

Looking ahead

The Lancet HIV Commission provides a timely roadmap for responding to this changing epidemic, but its success will depend on evidence generated where the need is greatest.

The international value of this evidence is clear. Historically, much of what’s known about ageing with HIV has come from wealthier settings, yet the overwhelming majority of older adults living with HIV now live – or soon will live – in low- and middle-income countries, particularly in sub-Saharan Africa. The HIV response must prepare for people growing older with HIV while recognising that older people remain at risk of acquiring it.

Written by Luicer Anne Ingasia Olubayo, Visiting Researcher at Sydney Brenner Institute for Molecular Bioscience, University of the Witwatersrand and Francesc Xavier Gomez-Olive Casas, Research Manager at MRC/Wits Agincourt Research Unit, University of the Witwatersrand

This article is republished from The Conversation under a Creative Commons license. Read the original article.