South Africa had roughly 800,000 people over 50 living with HIV in 2015. A decade later, that figure has more than doubled to around 1.9 million, and mathematical modelling projects it will exceed 3.6 million by 2035. The country’s health system, built largely around keeping people alive, is now confronting a harder question: how to keep them well.
The Southern African HIV Clinicians Society has published the first comprehensive clinical guidelines in South Africa designed specifically for people aged 50 and older living with HIV. Released in the Southern African Journal of HIV Medicine, the framework draws on contributions from a dozen experts spanning infectious diseases to palliative care. Its arrival reflects a demographic shift that has caught the health system, by most accounts, underprepared.
The transformation is a product of both success and delay. The delayed rollout of antiretroviral treatment during the early 2000s, when the government was reluctant to make therapy widely available, meant that many people who contracted HIV then survived only once treatment eventually reached them. Those patients now face decades of life with the virus, and the conditions that come with ageing.
Dr Camilla Wattrus, Clinical Director at the Southern African HIV Clinicians Society and one of the guidelines’ authors, frames the core challenge plainly: “Antiretroviral therapy has expanded the lifespan of people with HIV, but we must now also consider how to preserve the ‘health span’ in this group.” Living longer and living well are not the same thing.
The gap between the two is measurable. Nomathemba Chandiwana, Chief Scientific Officer at the Desmond Tutu Health Foundation and a co-author of the guidelines, notes that older people living with HIV have approximately 16 fewer years in good health compared to HIV-negative peers. For those who began antiretroviral treatment while their immune systems were still relatively intact, the gap narrows to about 9.5 years. That is still a substantial burden.
Meanwhile, the cause-of-death picture has shifted in ways that demand a clinical rethink. Data from Thembisa, South Africa’s leading HIV mathematical model, shows that between mid-2024 and mid-2025, there were 53,000 HIV-related deaths but 54,000 deaths from non-HIV-related causes among people living with HIV. People with HIV now develop the same age-related diseases as the general population, but evidence suggests they develop them earlier. Clinicians focused narrowly on viral suppression risk missing those threats entirely.
The guidelines address this through practical, implementable steps. They call for integrating geriatric screening into routine HIV clinical visits, raising healthcare worker awareness of the specific needs of older patients, and applying World Health Organisation principles for integrated care, emphasizing prevention before frailty sets in and person-centred assessment across disciplines beyond physicians alone.
The clinical content covers hypertension, cancer, and polypharmacy (defined as taking more than five medications simultaneously). Social barriers also receive attention. Older people are frequently perceived as unlikely to contract HIV, which drives lower testing rates and reduced uptake of prevention tools. Physical access to facilities and gaps in worker awareness compound the problem.
Wattrus is direct about what implementation requires. “Most of the recommendations are not complicated or costly,” she says. Training primary care workers to incorporate brief frailty screenings into routine appointments is a straightforward starting point. Several geriatric assessments need only a chair and a few minutes. Aligning appointments across conditions, cutting unnecessary referrals, and addressing social factors like poverty and isolation can all be done within existing service structures.
Medication review is another high-yield, low-cost intervention. Examining drug lists to identify unnecessary prescriptions and flag interactions requires no specialist input but can significantly improve patient outcomes. Chandiwana points to geriatric care health cards, similar to systems used for children, as a practical tool for tracking screening across visits, alongside community engagement to build health literacy around ageing.
The binding constraint is specialist capacity. South Africa has fewer than 50 geriatric specialists nationwide. Broader geriatric training across primary care, including nurses and community health workers, is not optional. Chandiwana frames the guidelines as a prompt for government action before the system faces greater strain. “Investment in scalable, simple systems for people who are ageing, both with HIV and without, would be fantastic, but that needs money,” she says.
Whether the guidelines translate into changed practice at the primary care level, where most of South Africa’s 1.9 million older HIV patients are seen, is the question that will determine their real-world value.