South Africa's HIV Services Face Surge in Aging Patient Caseload; New Clinical Protocols A

South Africa’s health system is managing 1.9 million people over 50 living with HIV, a cohort that has more than doubled since 2015 and is projected to exceed 3.6 million by 2035. To address this demographic reality, the Southern African HIV Clinicians Society has published the country’s first clinical guidelines specifically designed for older people living with HIV, establishing practical protocols for a resource-constrained system now confronting a patient population that barely existed two decades ago.

The guidelines, published in the Southern African Journal of HIV Medicine, draw on input from a dozen experts spanning infectious diseases, palliative care and related disciplines. Their emergence reflects a stark operational gap. In 2015, approximately 800,000 people over 50 were living with HIV in South Africa. By 2025, that figure had reached 1.9 million, representing 24 percent of the country’s estimated 7.9 million HIV-positive population.

This expansion stems partly from South Africa’s delayed antiretroviral rollout. Many people in this cohort contracted HIV in the early 2000s when the government resisted making treatment widely available, meaning they started therapy years or decades after infection. That delay fundamentally alters long-term health outcomes. Antiretroviral therapy has extended lifespan, but the guidelines confront an uncomfortable truth: length of life does not automatically translate to quality of life.

Dr Camilla Wattrus, clinical director at the Southern African HIV Clinicians Society and one of the guidelines’ authors, frames the delivery challenge directly. “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.” That distinction between living longer and living well defines the operational imperative driving the new framework.

The health burden is quantifiable. Nomathemba Chandiwana, chief scientific officer at the Desmond Tutu Health Foundation and a guideline co-author, notes that older people living with HIV experience approximately 16 fewer years in good health than people without HIV, though this gap narrows for those who began treatment while their immune systems remained relatively intact. The figure originates from a 2020 JAMA study comparing health outcomes among insured populations in the United States. For people with HIV who started antiretroviral treatment with CD4 counts above 500, the difference in healthy years fell to 9.5.

Meanwhile, a parallel concern is complicating clinical practice. Healthcare workers focused on HIV-specific metrics like viral suppression may overlook age-related diseases that strike people with HIV earlier than the general population. Recent data from the Thembisa mathematical model, South Africa’s leading HIV projection tool, reveals a sobering threshold: during the year from mid-2024 to mid-2025, there were 53,000 HIV-related deaths but 54,000 deaths from non-HIV causes among people with HIV. That crossover signals that the health system must now address conditions of aging as aggressively as it manages viral suppression.

The guidelines establish five core objectives: raising healthcare worker awareness of older HIV patients’ specific needs; promoting an aging-informed approach to care; highlighting evidence-based practices; providing resources for workers, patients and caregivers; and guiding clinical settings in integrating geriatric care into HIV services. The framework follows World Health Organization principles for integrated care of older people, emphasizing prevention before frailty and person-centered assessment involving multidisciplinary teams.

Operationally, the guidelines address concrete bottlenecks. Older patients face elevated risks of comorbid conditions like hypertension and cancer, complications from polypharmacy when taking more than five medicines concurrently, and social barriers including lower HIV testing rates. System-level gaps compound these issues: restricted facility access, worker unfamiliarity with HIV-related risks in aging populations, and insufficient holistic care coordination.

The guidelines specify comprehensive screening schedules with particular attention to geriatric syndromes including frailty and cognitive impairment. Wattrus describes the intended shift in clinical practice: “The idea is that every visit with an older patient involves more than just routine HIV care and that it becomes a conversation about how that person is functioning and living.”

Treatment protocols require careful antiretroviral selection. The guidelines caution against tenofovir disoproxil fumarate combinations in patients with osteoporosis, bone fractures or kidney impairment, recommending tenofovir alafenamide or abacavir as alternatives, though abacavir carries cardiovascular contraindications. CD4 recovery may proceed more slowly in older patients, but viral suppression remains the primary goal. More information on South Africa’s approach appears at https://www.dailymaverick.co.za/article/2026-08-02-how-sa-aims-to-keep-people-with-hiv-healthier-for-longer/

Implementation feasibility hinges on simplicity and cost. Wattrus notes that most recommendations avoid expensive interventions. Healthcare worker training, particularly at primary care level, forms the essential foundation. Geriatric screening tests like frailty assessments require minimal equipment (Chandiwana points out that several tests need only a chair). Aligning appointments across conditions, reducing unnecessary referrals and addressing social determinants like poverty and isolation represent low-cost adaptations.

Medication review is another high-yield, low-cost strategy. Routinely identifying unnecessary drugs and checking interactions requires no specialist input yet can produce significant clinical benefit. Chandiwana suggests rolling out geriatric health cards to track screening, mirroring child health monitoring systems, and expanding community health literacy around aging.

Structural constraints remain serious. South Africa has fewer than 50 geriatric specialists. Broader geriatric training across the healthcare system, including for primary care nurses and community health workers, faces real resource limitations. Chandiwana frames the guidelines as an opportunity for government investment in scalable systems serving both HIV-positive and general aging populations, but acknowledges such expansion requires sustained funding. The guidelines provide the framework. Whether the health system can allocate resources to operationalize them across a rapidly expanding older population is the question that now faces implementers on the ground.