Effective antiretroviral therapy (ART) has changed the course of human immunodeficiency virus (HIV) infection from being considered a fatal illness to a chronic manageable condition. This has enabled people to grow old living with HIV. The number of people who are more than 50 years old and living with HIV has increased globally because of the success of national ART programmes and the control of new infections amongst the elderly.¹ The life expectancy of people living with HIV (PLWH) has increased substantially, approximating that of the general population in high-income countries.^2,3 Similar gains in life expectancy have also been reported in some countries in sub-Saharan Africa.⁴ It seems likely that the median age of PLWH will increase with time as more and more people garner the survival benefits of effective ART. It is now critical to promote healthy ageing amongst PLWH, an achievement that some have described as the ‘fourth 90%’.⁵

As PLWH age, they face many of the same health challenges as faced by older individuals in the general population. Additionally, ageing PLWH face new challenges such as accelerated ageing and higher rates of comorbidities including cardiovascular, renal and metabolic diseases.⁶ Comorbidities occur at high rates at all ages amongst PLWH but become increasingly important as this population ages. People living with HIV also develop geriatric syndromes and frailty earlier as compared to HIV uninfected people.⁷ Certain ART drugs such as protease inhibitors may increase cardiovascular risk because of poor metabolic profile including hyperlipidaemia compared to other drugs such as the non-nucleoside reverse transcriptase inhibitors.⁸ There has been a documented increase in the rate of all cancers, particularly lung, prostate, colorectal, anal, cervix, lymphomas and breast as PLWH age.⁹ However, it is important to note that cancer rates increase with age in everyone.

Although there is a growing body of research on HIV and ageing, evidence from low- and middle-income countries that bear the highest burden of HIV infection is scarce.^10,11 The expectations and management of elderly PLWH differ from those of younger patients and may change over time. In this study, we profiled the demographic and clinical characteristics of elderly patients receiving comprehensive HIV care at Newlands Clinic (NC), Harare, Zimbabwe, as of 01 October 2019. There is evidence that the distribution of comorbidities may differ by sex¹²; therefore, we analysed and reported our results by sex.

Of the 6543 patients in care at NC, 1688 (25.8%) were above the age of 50 years (Table 1). The median age at analysis was 56 years (IQR: 52–61), with 72.2% of elderly patients aged between 50 and 60 years, and no difference by sex. The median duration of ART was 10.9 years (IQR: 7.1–13). At enrolment into care, 51% were married, 32% widowed, 6% divorced and 11% single. There was a far lower proportion of married women than married men (31% vs. 82%). The most recent median CD4 cell count in this cohort was 464 cells/mm³ (IQR: 327–628), which was higher in females than males (526 vs. 377). Over 90% of all patients were virally suppressed, with VLs below 50 copies/mL. Only 1.8% of patients had a VL > 1000 copies/mL. No sex differences were observed in the VL distribution. Almost half of the elderly patients were either overweight or obese and 8% were underweight. Women were more likely than men to be overweight and obese (32% and 25% vs. 18% and 7%, respectively). Most patients (64.1%) received the fixed dose ART combination of tenofovir, lamivudine and dolutegravir.

We found that a quarter of PLWH receiving care at NC were older than 50 years. The majority of these elderly patients had received ART for over 10 years. Most men were married; the majority of women were widowed. This cohort of elderly patients had well-controlled HIV infection with evidence of good immunological status. A high prevalence of overweight or obesity was reported, particularly amongst women. Comorbidities were common, notably hypertension, malignancies (far higher in women than in men) and CKD (higher in men than in women). Nearly 20% of patients had at least two chronic comorbidities, and 5.6% had three.

The goal of ART is sustained suppression of HIV replication. Our results show that elderly patients with HIV achieve high rates of viral suppression. This finding is consistent with the results from other studies.¹⁰ Older patients receiving ART have demonstrated good medication adherence and this plays a key role in achieving high rates of viral suppression.^14,15

Although only half of our patients were married at the time of enrolment into care, over 80% of men were married. The higher proportion of marriage amongst men may be because of the fact that men are more likely to remarry after the loss of a spouse or after divorce.¹⁶ Older patients with HIV face a number of challenges that may affect their quality of life. Loss of partners and friends may lead to social isolation, depression and poor adherence to medicines.¹⁷ Additional stressors such as unemployment and poverty may further worsen the quality of life. The high number of comorbidities and pill burden may negatively affect medicine adherence. Interactions between ART and other medications are a major consideration amongst the ageing population.

The high prevalence of chronic non-AIDS diseases in this cohort is consistent with the findings from other studies which have showed an increased number of comorbidities in PLWH at all ages, but particularly as this population ages.⁶ Hypertension is now recognised as an important chronic comorbid condition of PLWH and is associated with increased morbidity and mortality.¹⁸ Screening and optimal management of hypertension must become part of the comprehensive care of elderly PLWH.

The prevalence of CKD was high. Numerous risk factors are involved in renal disease in PLWH, such as age, black race, DM, hypertension, low CD4 counts and certain ART medicines like tenofovir disoproxil fumarate.¹⁹ All HIV-positive patients especially the elderly must have annual measurements of their renal function. Diabetes mellitus was far less common than hypertension. As has been previously reported, the risk of developing DM in PLWH is not well-established, and studies have not consistently shown a relationship between DM and HIV.^20,21 However, some studies have shown that the risk of DM increases amongst patients receiving ART.²²

A large number of elderly patients suffered from different forms of malignancies, which were differently distributed by sex. Human papilloma virus (HPV)-related malignancies were the leading diagnosed cancers. Almost 70% of the women with malignancies had HPV-related CIN3. The HPV-related anogenital malignancies will remain a challenge amongst HIV-infected men and women even in the era of effective ART.²³ Screening for high-risk HPV infection should become part of the care of HIV-positive women. The estimated cumulative incidence for other cancers such as non-Hodgkin’s B-cell lymphoma, lung cancer, liver cancer and Hodgkin’s lymphoma increased amongst HIV-infected patients.²⁴ Routine screening for common cancers should be part of the comprehensive care of HIV-infected elderly patients.

Our study was strengthened by very high levels of data completeness. However, our study was limited as we used data from a single clinic only. Frailty, cognitive impairment and other geriatric syndromes that are common and important in HIV were not included in comorbidities as data on these are not routinely collected. Furthermore, assessing cancers cross sectionally as we did, without consideration of those who have died of cancer prior to the data pull, underestimates the true cancer burden. We assessed all cancers ever diagnosed (historical). We acknowledge that although these data are interesting, they are potentially misleading. Despite these limitations, we believe that our results are important to healthcare providers and policymakers.

Our data demonstrates that in Africa high rates of virological suppression can be achieved amongst elderly patients on ART. However, the high rates of obesity (especially amongst women) and hypertension in this population need to be addressed. The prevalence of pre-malignant cervical disease amongst elderly women is high; and hence, routine cervical cancer screening is essential for elderly women living with HIV.

The time has come for HIV treatment programmes to draw on a wide range of medical disciplines and evidence-based screening procedures for the multidisciplinary care of the ageing HIV-infected population. Age-appropriate monitoring protocols must be developed to ensure optimum quality of care for elderly HIV-positive individuals.