Guideline

Southern African HIV Clinicians Society clinical guideline for the management of older people with HIV

Evan Shoul, Nomathemba Chandiwana, Sathya Jogulu, Rene Krause, Coceka Mnyani, Zainab Mohamed, Jeremy S. Nel, Sam Nightingale, Catherine Orrell, W.D. Francois Venter, Camilla Wattrus, Linda-Gail Bekker

Received: 24 Feb. 2026; Accepted: 24 Apr. 2026; Published: 11 June 2026

Copyright: © 2026. The Author(s). Licensee: AOSIS.
This work is licensed under the Creative Commons Attribution 4.0 International (CC BY 4.0) license (https://creativecommons.org/licenses/by/4.0/).

Introduction

The successful global scale-up of antiretroviral therapy (ART) has transformed HIV into a chronic, easily manageable condition. Consequently, the population of people with HIV (PWH) are now also ‘ageing’ with HIV.¹ Among adults living with HIV in the African region, 15% are aged at least 50 years, and modelling predicts that by 2040 this proportion will increase to 27% (9.1 million).² While ART has expanded the lifespan of PWH,³ healthcare workers (HCWs) must now consider how to preserve the ‘health span’ in this group.⁴ This epidemiological shift presents a new set of clinical challenges to clinicians, the health system and societal support structures.

Older people with HIV (OPWH) may experience ‘accelerated’ or ‘premature’ ageing. They face a higher risk of increased burden of non-communicable diseases (NCDs), geriatric syndromes (e.g. frailty, cognitive decline, polypharmacy), and social isolation at an earlier age compared to their HIV-negative peers.⁵ This is because of a combination of chronic inflammation from the ongoing effects of HIV, long-term ART (side) effects, and conventional age-related risks.⁶

This guideline provides a comprehensive, evidence-based and pragmatic framework for the management of OPWH within the South African (SA) healthcare context. It moves beyond viral suppression to advocate for a holistic, person-centred, geriatric-informed approach that prioritises quality of life, functional independence, and the management of multimorbidity. Recommendations are intended for use by HCWs across the spectrum of care, from primary health clinics to tertiary institutions, and in both the public and private sectors. Some of the suggested screening modalities and interventions may be aspirational for the SA public health sector but are included for settings with more resources.

This guideline incorporates principles from the WHO Integrated Care for Older People (ICOPE) framework,⁷ which emphasises prevention prior to frailty, person-centred assessment, and the involvement of HCWs other than doctors. Integrated Care for Older People provides a structured, task-shiftable five-step pathway (Box 1) for detecting and managing declines in intrinsic capacity (IC), defined as ‘the composite of an individual’s physical and mental capacities’. The six IC domains (locomotion, vitality, vision, hearing, cognition, and psychological wellbeing) have been incorporated into the key geriatric syndromes described in this guideline.

The ageing HIV epidemic in South Africa

HIV and the associated chronic immune activation may accelerate the ageing process, leading to an earlier onset of age-associated comorbidities.⁶ There is an increased risk of geriatric syndromes (Box 2) in PWH, including frailty, polypharmacy, cognitive decline, mood disorders, and sensory dysfunction.⁶ This necessitates awareness, proactive screening and intervention at a younger chronological age than would be typical in HIV-negative populations.

A geriatric assessment provides a complete view of a patient’s function, cognition and health, and improves prognostication and treatment decisions.⁸ As the population with HIV grows older, the application of the geriatric principles can enhance the quality of care.^8,9

This guidance is designed to:

• Raise HCWs’ awareness of the needs and concerns of PWH who are ≥ 50 years old.
• Inform HCWs about an ageing-related approach to OPWH.
• Highlight good practices to help HCWs provide optimal care for this population.
• Provide resources about ageing with HIV for HCWs, their patients and their patients’ carers.
• Guide clinical settings in implementing geriatric care into HIV clinical practice.

Within the HIV prevention, care and treatment continuum in low- and middle-income countries (LMICs), older people face specific challenges. These are summarised in Table 1.

Principles of care for older people with HIV

An approach to ageing in HIV care should include¹¹:

• Discussing the effects of ageing with patients who are ≥ 50 years old and living with HIV, to help identify medical priorities and evaluate physical function. Such conversations may also prompt consideration of advance directives and help patients recognise the effects of age-associated stigma.
• Taking a proactive approach to ageing to help prevent or slow functional and social decline.
• Becoming familiar with the available screening tools, and local and national services for older people.
• Screening for frailty and functional decline to enable early identification of at-risk patients.
• Including nonpharmacologic measures, such as exercise, nutrition and socialisation, which are essential to patients’ physical and emotional health.
• Using a framework such as the ‘geriatric 5Ms’ (mind, mobility, medications, multimorbidity, and matters most) to help inform the choice of screening tests or communicate geriatric concepts. It is also important that screening and assessment be performed with validated tools that assess specific domains.
• Evaluating medications at every clinical visit to eliminate unnecessary or toxic medications, to identify and mitigate potentially harmful drug–drug interactions (DDIs), and reduce the potential for polypharmacy.
• Facilitating and simplifying access to care and services (e.g. aligning appointments and reducing referrals) as patients’ care needs increase to improve overall adherence to and satisfaction with treatment.
• Being familiar with the benefits and local sources of palliative care to help recognise and meet the needs of patients with serious illnesses.
• Enabling task-shifting and cadre-appropriate care in resource constrained settings by applying the ICOPE principles.

The following principles should underpin all clinical interactions with OPWH¹¹:

• Holistic assessment: Ensuring every consultation extends beyond HIV-specific care and markers (CD4, viral load) to include a review of functional status, mood, cognition, social support, and overall quality of life.
• Multimorbidity management: Managing HIV as one of several chronic conditions. Control of hypertension, type 2 diabetes, and other NCDs is equally critical for long-term outcomes.
• Polypharmacy review: To minimise adverse effects and interactions, critically reviewing all medications at every visit, including prescribed, over-the-counter, and traditional medicines.
• Prevention and health promotion: Prioritising prevention interventions including vaccinations, lifestyle modifications, and screening for geriatric syndromes.
• Shared decision-making: Engaging patients and their families, carers and other support structures in all care decisions.
• Multidisciplinary team approach: Ensuring the input of a pharmacist, dietitian, physiotherapist, occupational therapist, social worker and mental health professional as required.
• Intrinsic capacity (IC) monitoring: Tracking trajectory across the six IC domains (locomotion, vitality, vision, hearing, cognition, and psychological wellbeing) at each visit. A decline in a domain should trigger an in-depth assessment (ICOPE Step 2, Box 1) and individualised care planning (ICOPE Step 3, Box 1).

Comprehensive health assessment

The Comprehensive Geriatric Assessment (CGA) is valuable, but long and complex. An adapted semi-structured, regular geriatric assessment can be incorporated into primary HIV care for patients ≥ 50 years. Table 2 outlines the minimum recommended screening schedule for all OPWH and integrates ICOPE screening recommendations. The frequency of assessment serves as a guide and should be adapted depending on need and resources. Screening can be conducted by any trained HCW, with more complex assessment or examination, and management undertaken by nurses or doctors within their scope of practice, and with referral to a specialist when needed. Routine HIV care should be provided alongside this.

Immunisations

Age-related decline in immune function is compounded by HIV, leading to suboptimal responses to vaccines and increased susceptibility to vaccine-preventable diseases. Immunisations are a critical part of preventive care among OPWH. Vaccine recommendations are detailed in Table 3.

Optimising antiretroviral therapy

If a patient is not yet on ART, start ART at the same visit regardless of their CD4 count. Monitor the viral load response to ART as per the SA national guidelines (Box 4).¹⁵ Be aware that CD4 recovery may be slower and blunted compared to younger individuals. This highlights the importance of viral suppression as the primary treatment goal.

Choosing a regimen

The goal is to select an ART regimen that is potent, well-tolerated, has a high barrier to resistance; and has minimal potential for DDIs, and bone and renal toxicities. When choosing a first-line regimen, consider the following:

• Avoid tenofovir disoproxil fumarate (TDF) in patients with, or at high risk for, osteoporosis, bone fractures, or renal impairment (estimated glomerular filtration rate, eGFR < 60 mL/min). Alternative regimens in these patients include:
  • Tenofovir-alafenamide (TAF)-based combination, for example TAF-emtricitabine-dolutegravir. TAF has a more favourable bone and renal profile than TDF.
  • Abacavir-based regimen, for example abacavir-lamivudine-dolutegravir. Abacavir is contraindicated in patients positive for HLA-B*5701 and should be used with caution in patients with a high cardiovascular risk.
  • Dual therapy in selected patients: Lamivudine-dolutegravir is available as a single tablet regimen in the SA private sector. However, it should not be initiated in individuals with a HIV viral load > 500 000 copies/mL, a CD4 count < 200 cells/uL, or those with chronic hepatitis B or any prior history of virological failure. Similarly, rilpivirine-dolutegravir (also available as a single tablet regimen) can be used in patients who are viralogically suppressed without a history of prior virological failure.

For more details on selecting a first-line regimen, opportunistic infection prophylaxis, and renal disease, see https://www.sahivsoc.org/Guidelines/Module11, https://www.sahivsoc.org/Guidelines/Module27 and https://www.sahivsoc.org/Guidelines/Module21, respectively.¹⁶

Monitoring on antiretroviral therapy

Age-related declines in renal and hepatic function can alter drug metabolism. Dose selection must be cautious and guided by organ function. It is important to monitor the following:

• Renal function: For patients on TDF, monitor creatinine and eGFR at baseline, at 3 months, and then 6-monthly. See https://www.sahivsoc.org/Guidelines/Module15 for more detail.¹⁶ For details on the recommended baseline evaluation, see https://www.sahivsoc.org/Guidelines/Module7.¹⁶
• Weight: Monitor the patient’s weight trajectory. Significant weight gain on an integrase-strand inhibitor (e.g. dolutegravir) or a TAF-based regimen may require nutritional and lifestyle counselling. Women are at higher risk of weight gain.
• Adherence: OPWH may have better adherence than younger cohorts, but screen for barriers related to polypharmacy, cognitive decline, and mental illness.

Managing adverse effects on antiretroviral therapy

Neuropsychiatric and metabolic side effects should be monitored:

• If a patient on efavirenz or dolutegravir reports significant insomnia, mood changes, or depression, switch to an alternative agent (e.g. rilpivirine in virologically suppressed patients, or a protease inhibitor [PI]-based regimen).
• Manage weight gain, dyslipidaemia, and glucose intolerance proactively with lifestyle and pharmacological interventions. Avoid unnecessary ART switches.

Geriatric syndromes

Frailty

Frailty increases vulnerability to stressors and is a powerful predictor of negative health outcomes in older people. To screen for frailty, use the FRAIL questionnaire (Box 3). A score ≥ 3 indicates frailty.

Manage frailty as follows:

• Help the patient to develop an exercise plan: Supervised resistance and balance training are most effective. Refer to a physiotherapist or occupational therapist if necessary and if resources allow.
• Assist with good nutrition: Ensure adequate protein and calorie intake to prevent sarcopenia. Refer for nutritional support if necessary and if resources allow.
• Optimise comorbidities: Ensure good control of NCDs.
• Review medications: Deprescribe medications that contribute to fatigue, weakness or dizziness.
• Assist with social support: Address isolation and lack of support. Refer to a social worker if necessary and if resources allow. Also see Box 4.

Polypharmacy

Polypharmacy is the use of ≥ 5 medications. It is common among OPWH and a major driver of adverse drug events, non-adherence, and hospitalisations.^18,19 Managing polypharmacy is challenging and ideally the primary carer should regularly review all medication.

Where a medication is indicated, a good general rule in OPWH is to start with a low dose and titrate the dose upwards moderated by response and side effects.

Manage polypharmacy as follows:

• Create a complete an accurate list of all medications, including prescription, over-the-counter and traditional medicines.
• Identify potentially inappropriate medications (e.g. sedatives, anticholinergics, duplicate drug classes).
• Check for DDIs for every new drug prescribed using an interaction checker (Box 4).
• Taper and stop any non-essential medications and where risks outweigh benefits.²⁰
• Simplify prescribed medication by using combination pills (e.g. single-pill ART, fixed-dose combinations) to reduce pill burden.

Cognitive impairment

HIV itself may cause cognitive impairment and OPWH are at higher risk for all-cause dementia.^21,22 Causes of cognitive impairment include those caused directly by HIV (HIV-associated brain injury [HABI]) and those caused by comorbid factors (Table 4).²² Progressive cognitive impairment caused directly by HIV (active HABI) tends to be associated with incomplete HIV control in the plasma and/or cerebrospinal fluid (CSF), whereas neurodegenerative diseases (such as Alzheimer’s disease) can occur in OPWH with HIV suppression.

Older people with HIV should be encouraged to report issues with memory, concentration and functioning, and any concerns should prompt assessment. This should be corroborated or supplemented by an informant, such as a carer or family member, as appropriate. Routine screening using a cognitive tool in asymptomatic people is not recommended.

Choice of cognitive test will depend on time and available expertise. Commonly used tools include the Montreal Cognitive Assessment (MoCA), the Mini Mental State Examination (MMSE), and the Addenbrooke’s Cognitive Examination (ACE-III) (see Box 4). These tools have been developed in the global north, and cut-offs for abnormality do not apply across all populations. Results should therefore be interpreted in the context of the individual’s educational and sociodemographic background. The International HIV-Dementia Scale has low sensitivity and is no longer recommended.

Assess cognitive impairment as follows:

• Ideally include an informant (e.g. a relative or carer) when taking a history, as cognitively impaired people may lack insight into their difficulties. Confidentiality should be preserved and consent obtained.
• Screen with a functional assessment (tools include IQCODE, Barthel, Lawton). See Box 4 for links to tools.
• Functional assessment can also predict dementia stage when cognitive testing is unreliable.
• Assess for depressive symptoms as these can contribute to cognitive symptoms and/or confound cognitive testing.

Perform investigations depending on available resources:

• Exclude reversible causes including hypothyroidism (thyroid stimulating hormone, TSH), vitamin B12 deficiency (serum B12), and syphilis (TPHA).
• Consider neuroimaging where resources permit: Computerised tomography (CT) brain imaging can indicate comorbid pathology including cardiovascular disease (CVD), traumatic brain injury or previous opportunistic infection. Magnetic resonance imaging (MRI) may additionally show diffuse white matter signal changes indicating legacy HABI, or focal cortical atrophy indicating a neurodegenerative process such as Alzheimer’s disease.
• Perform a lumbar puncture only in those with suspected active HABI. This should include measurement of CSF HIV viral load and investigating possible central nervous system infections, such as neurosyphilis.

Management of cognitive impairment:

• Ensure sustained HIV viral suppression.
• Optimise vascular risk factors: control hypertension, diabetes, and hyperlipidaemia.
• Think of and treat comorbidities: depression/psychiatric illness, delirium, alcohol, seizures.
• Avoid ART neurotoxicity: If on efavirenz, switch ART as this is associated with cognitive side effects, which can be severe.²⁴
• Avoid sedatives and anticholinergics including tricyclic antidepressants.
• If needed, offer information and practical support.²⁵ Refer to social worker if necessary and if resources allow.

Falls prevention

It is important to screen OPWH for fall risk. Use a simple physical performance test such as:

• Timed-Up-And-Go (TUG)²⁶:
  • Ask the patient to stand up from chair, walk 3 m, turn, walk back and sit down.
  • Results: < 10 s normal; >14 s increased fall risk; > 20 s frailty or mobility impairment.
• 5 times sit to stand (5 x STS)²⁷:
  • Ask the patient to sit on chair, fold their arms, stand up and sit down five times.
  • Results: > 15 s fall risk; > 20 s or unable is frailty.

Evaluate for causes of fall risk including:

• Medications: sedatives, antidepressants, antihypertensives.
• Environmental: home hazards, poor lighting, loose rugs.
• Medical: orthostatic hypotension, visual impairment, neuropathy, foot problems.
• Neuromuscular: weakness (sarcopenia), poor balance.

Managing falls risk includes exercise programmes (balance and strength training), medication review and management of orthostatic hypotension. If resources allow, physiotherapist or biokineticist referral is recommended for those at high risk. Self-exercise is recommended for those at low risk. If resources allow, consider referral to an occupational therapist for home safety modifications and refer to podiatrist as needed.

Mental health and psychosocial wellbeing

Depression, anxiety, and substance use disorders are common in OPWH, and are associated with reduced quality of life, poor ART adherence, functional decline, and increased morbidity.^28,29,30 These conditions are worsened by social and structural stressors, stigma, loneliness, poverty, food insecurity, and the demands of managing multiple comorbidities.^31,32

Certain antiretrovirals have been associated with neuropsychiatric symptoms in susceptible individuals and should be reviewed in the context of new or worsening symptoms. Efavirenz remains a commonly used non-nucleoside reverse transcriptase inhibitor (NNRTI), despite evidence of neuropsychiatric side effects such as sleep disturbances, suicide, depression and neurocognitive effects.²⁰ Dolutegravir use in OPWH has also been associated with sleep and mood alterations, anxiety, depression, and psychosis.²⁰

Routine mental health screening should be integrated into routine HIV care and done at a primary care level:

• Annual screening is recommended with brief primary healthcare tools such as the Patient Health Questionnaire-2 (PHQ-2) for depression and Generalised Anxiety Disorder-2 (GAD-2) for anxiety. Should these screen positive, more detailed tools such as PHQ-9 and GAD-7 should be used. These are effective across all resource settings.^33,34 See Box 4 for links to tools.
• Always assess for suicidal ideation in patients with depression. This is a psychiatric emergency that if present requires immediate referral.

Management includes³⁵:

• Exclude underlying medical conditions and optimise treatment of chronic comorbidities, such as hypothyroidism, anaemia, tuberculosis (TB), diabetes
• Screen for and manage substance use, for example alcohol use, over-the-counter analgesics.
• Optimise first-line pharmacotherapy: use a selective serotonin reuptake inhibitor (SSRI) such as fluoxetine or citalopram and ‘start low, go slow’ or Serotonin-Noradrenaline Reuptake Inhibitors (SNRIs) such as duloxetine, especially in HIV patients with sensory neuropathies. Titrate to clinical response which can take up to 8 weeks. Be aware of potential DDIs with ART, for example, ritonavir. Use an interaction checker (Box 4).
• Refer for psychotherapy: refer for individual therapy and/or family counselling if available. The ‘Friendship Bench’ model is an effective and affordable task-shifted intervention which relies on peer or lay support in a community-based setting.
• Assist with social support: facilitate access to support groups, community clubs, and social grants to address isolation and poverty.
• For more information see Chapter 16 of the National Standard Treatment Guidelines for Primary Health Care (Box 4).³⁵

Managing comorbid non-communicable diseases

Cardiovascular disease

Older people with HIV on ART have double the risk for myocardial infarction and heart failure when compared with the general population. Along with traditional risk factors, heightened inflammation and ART toxicities contribute to these risks.³⁶ Certain antiretrovirals (e.g. abacavir, lopinavir-ritonavir), though not others (e.g. atazanavir), are associated with increased risk of myocardial infarction.³⁷

Approaches to metabolic and cardiovascular risk are similar to those for the general population, with the following caveats:

• For risk calculation, use a standard CVD risk calculator, for example the Framingham score (see Box 4), acknowledging that it may underestimate risk in PWH.
• Modifiable risk factors warrant close attention, including smoking, diabetes, chronic kidney disease, substance use, depression, and hepatitis C.
• Avoid simvastatin and lovastatin if on PI-based ART because of DDIs. Preferred options are atorvastatin or rosuvastatin, with appropriate dosing.
• Abacavir has been inconsistently linked to elevated cardiovascular risk. Assess individualised risks and benefits. Tenofovir-containing regimens are preferred where possible.
• Low dose aspirin as primary prevention in older adults results in higher risk of major haemorrhage with no lower risk of CVD, and should therefore not be used.³⁸

Obesity

People with HIV are at increased risk of obesity as they age, especially with the use of certain antiretrovirals including the integrase strand transfer inhibitors (INSTIs) and TAF. While all ART and HIV itself cause weight gain, the underlying cause is not well understood. Common risk factors include advanced disease at ART initiation (low CD4/high viral load, low body mass index [BMI]), women, Black ethnicity, TAF versus TDF, and INSTIs versus PI- or efavirenz-based regimens.

Lifestyle interventions have limited long-term benefit, while newer obesity medications show promise. Research on new drugs in PWH is sparse and access is constrained by cost, availability, and provider expertise.

Obesity prevention strategies at ART initiation should focus on culturally and contextually appropriate counselling around diet and activity. Switching ART is generally not advised, except possibly from TAF to TDF, which may modestly reduce weight gain but must be balanced against renal and bone health risks.

Diabetes

Diabetes screening in OPWH should follow local guidelines and management, recognising that metformin and dolutegravir have a DDI, and a dose of 1g twice daily (total daily dose of 2 g) of metformin should not be exceeded.

Hypertension

Hypertension screening and management remains conventional for OPWH, with the only consideration being possible DDIs between the PIs and calcium-channel blockers, which may mean extra monitoring of hypotension side effects, and avoidance of nifedipine.

Osteoporosis

Osteoporosis is common in PWH because of multiple risk factors, including low BMI, hypogonadism, smoking, and the long-term effects of HIV infection and ART. This leads to higher fracture risk, morbidity, and mortality in OPWH.³⁹ Tenofovir disoproxil fumarate has been linked to significant bone mineral density (BMD) loss and higher fracture risk, and switching to TAF may reduce this toxicity.²⁰ Diagnosis is based on BMD measurement or a history of fragility fracture (vertebral, proximal femur, distal radius).

Screening for osteoporosis can be done as follows:

• A fracture risk assessment tool (FRAX) calculation (can be done without BMD result) and can be used as a simple screen even in low resource settings. Check ‘yes’ for secondary causes in PWH. If fracture risk is high, then refer for BMD screening. See Box 4 for a link to the tool.
• If resources allow, perform bone density screening using a DEXA scan for all women > 65 years and men > 70 years, or earlier in those with risk factors (e.g. steroid use, prior fracture, prolonged TDF exposure).

Management of osteoporosis should include^39,40,41:

• General measures:
  • Basic investigations can be performed to exclude secondary causes, such as calcium, parathyroid hormone (PTH), alkaline phosphatase (ALP), albumin, creatinine, full blood count (FBC) with erythrocyte sedimentation rate (ESR), TSH, serum protein electrophoresis (SPEP).
  • Encourage healthy eating, adequate calcium and vitamin D intake, and regular physical activity.
  • Advise the patient to limit alcohol and stop smoking.
  • Give supplemental calcium (500 mg/day – 600 mg/day) and vitamin D (600 IU/day – 800IU/day). Calcium supplements can reduce dolutegravir absorption. Advise patients to take calcium with meals and at least 2 h before or after dolutegravir.
  • Institute fall prevention strategies.
• ART switch:
  • Consider switching from TDF to TAF or abacavir in patients with osteoporosis or fragility fractures.
• Pharmacotherapy
  • Consider hormone therapy for post-menopausal women: oestrogen plus progestin
  • Give a bisphosphonate (first-line for most patients): ibandronate (orally or intravenously), alendronate orally (daily/weekly), zoledronate (annually, intravenously).
    • If medications are not tolerated or there is a poor clinical response, refer for specialised second line treatment.
    • Recommend ‘treatment holidays’ from bisphosphonates: after 5 years of alendronate, and 3–6 years of zoledronate, and consider treatment holiday with ibandronate after 5 years if fracture risk is low.

Renal function

Renal disease in OPWH can result from HIV infection itself (local infection and immune dysregulation), ART-related renal toxicity, genetic susceptibility and comorbid chronic kidney disease (CKD) risk factors such as diabetes, hypertension, and hepatitis B and C.

Age-related decline in renal function alters the pharmacokinetics of nucleoside reverse transcriptase inhibitors (NRTIs) such as TDF, lamivudine and emtricitabine.²⁰ As eGFR declines, NRTI doses should be adjusted as titrated against renal function. NNRTIs, PIs and INSTIs do not require renal adjustment. Risk factors for renal toxicity associated with TDF include poor baseline renal function, concomitant nephrotoxic medications, low BMI, older age and lower CD4 count.²⁰

Managing renal function should include:

• Monitor eGFR 6-monthly.
• Avoid nephrotoxic drugs (e.g. nonsteroidal anti-inflammatory drugs [NSAIDs], aminoglycosides) in patients with CKD.
• Dose-adjust lamivudine, emtricitabine, and TDF according to eGFR.
• TAF is preferred over TDF in CKD.
• If the patient is persistently proteinuric or dialysis is required, discuss and co-manage with a nephrologist.

For more detail, see www.sahivsoc.org/guidelines/Module21.¹⁶

Hepatic function

Many drugs used in PWH are metabolised by the liver. Age-related decline in liver function results in increased drug exposure with increased risks of adverse effects. Older people with HIV may present with more severe liver disease, particularly co-infection with Hepatitis B or C, metabolic disorders such as metabolic dysfunction-associated steatotic liver disease and hepatocellular carcinoma.²⁰

The least hepatotoxic first line regimen is TDF (or TAF) plus lamivudine (or emtricitabine) plus dolutegravir. For individuals with advanced liver disease (Child-Pugh class C), PIs and NNRTIs are best avoided. If their use is essential, closely monitor liver function for the first 3–6 months. Abacavir, which undergoes extensive hepatic metabolism, requires a dose reduction in the setting of advanced liver disease⁴²:

• Mild impairment (Child-Pugh Class A): 200 mg 12-hourly
• Moderate and Severe impairment (Child-Pugh Class B and C): contra-indicated.

Other common medications with a risk of hepatoxicity include cotrimoxazole and anti-tuberculous drugs, including tuberculosis preventive therapy (TPT) regimens. These medications should not be unnecessarily withheld in OPWH because of their clinical benefits. However, for individuals with pre-existing severe liver disease, an individualised risk-benefit assessment is essential, as such medications may not be appropriate in this context.

Patients with chronic hepatitis B require a tenofovir-based regimen (TDF or TAF).

For more information see: https://www.sahivsoc.org/Guidelines/Module20^.16

Lung health

Asthma and chronic obstructive pulmonary disease

Management of asthma and chronic obstructive pulmonary disease (COPD) in OPWH remains similar to the general population except when considering potential DDIs between ART and asthma medications. Use of PIs with inhaled or systemic corticosteroids and long-acting inhaled beta agonists may cause added toxicities in the asthma drugs and should be closely monitored.^43,44 Assess cumulative systemic corticosteroid exposure, as it may worsen age-related comorbidities, particularly osteoporosis.

Tuberculosis

Older people with HIV are at increased risk for both primary TB and reactivation of latent TB infection. Older people are more likely to develop extra-pulmonary and atypical forms of TB that are often harder to diagnose than conventional smear-positive pulmonary TB.⁴⁵ Prevention, screening and treatment of TB should follow National guidelines (Box 4), with the added caution of DDIs between rifampicin and ART (dolutegravir and PIs). Patients on TLD require an additional 50mg dolutegravir twice daily while on rifampicin. OPWH are more susceptible to adverse effects from TB treatment and require closer follow up.^45,46,47

Sleep problems

Sleep disturbances are common in OPWH and significantly impact mental health, neurocognitive functioning, cardiometabolic risk and overall functional status.^48,49,50 Poor sleep quantity and quality worsens anxiety, chronic pain, depression, and cognitive decline, while also increasing the risk of type 2 diabetes and hypertension.^{48,51,52,53,54}

Screening for sleep problems includes:

• Routinely enquire about sleep quantity, quality, timing, daytime sleepiness, and functional impact, with collateral history where appropriate.
• Use brief screening tools (Box 4) to identify common sleep problems, including the Epworth Sleepiness Scale (daytime sleepiness) and STOP-BANG (risk of obstructive sleep apnoea).
• Consider contributory factors, including depression, anxiety, chronic pain, alcohol use, ART-related effects, and polypharmacy.

Management should follow a stepwise approach, addressing reversible contributors before specialist referral:

• Identify and treat contributing conditions, including depression, anxiety, chronic pain, alcohol or substance use, cardiometabolic disease, and poorly controlled HIV.
• Review ART and concomitant medications in individuals with persistent or worsening sleep disturbance.
• Prioritise non-pharmacological approaches, including sleep hygiene education, physical activity, and cognitive behavioural therapy for insomnia (CBTi) where available.
• Refer for diagnostic sleep studies and specialist care if resources allow, particularly when obstructive sleep apnoea is suspected.
• Avoid the routine use of benzodiazepines, benzodiazepine receptor agonists (e.g. zolpidem, zopiclone), and tricyclic antidepressants for insomnia in older adults, because of increased risk of falls, cognitive impairment, and other adverse events.⁵⁵
• Where pharmacological treatment is considered, use the lowest effective dose for the shortest duration, with close monitoring for adverse effects and DDIs.
• In selected cases with suspected circadian rhythm disruption, chronotherapy (timed light exposure and/or melatonin) may be considered in specialist or well-supported settings.

Sexual and reproductive health

Sexual and reproductive health (SRH) needs in older people are often neglected. While condom use declines with age, sexual activity continues, leading to increased sexually transmitted infection (STI) risk. The risk of STIs, including HIV, is often not considered in older people, delaying diagnosis and initiation of treatment.^56,57

Women

Sexual health is impacted by menopause and its physiological and psychological symptoms. Menopause changes the vaginal microbiota, increasing the risk of HIV transmission and acquisition.⁵⁸ Hormone therapy can be considered after an individualised risk–benefit assessment. Contraception remains necessary until menopause is confirmed, defined as at least 12 months of amenorrhoea. The choice of contraception should be guided by existing comorbidities.

Men

Common sexual dysfunctions in older men include erectile dysfunction, ejaculatory disorders, and primary testicular failure. Treatment options for erectile dysfunction range from lifestyle modifications and medical management to oral phosphodiesterase type-5 inhibitors (PDE5i), such as sildenafil. While PDE5 inhibitors are effective, they have potential DDIs with nitrates and some ART. Dose adjustments of PDE5 inhibitors may be required if given with PIs.⁵⁹

Malignancies

Screening for malignancy is essential in OPWH because of increased cancer risk from ageing, longer survival on ART, and premature ageing in PWH.⁶⁰

People with HIV are at increased risk of AIDS-defining cancers (e.g. Kaposi sarcoma, non-Hodgkin lymphoma, and cervical cancer) and non-AIDS-defining cancers (e.g. Hodgkin lymphoma; anal, lung, liver, and oropharyngeal cancers).^61,62

Appendix 1 details cancer screening recommendations in OPWH.

Strategies to reduce cancer risk include:

• Lifestyle modifications: Smoking cessation, reduced alcohol intake, obesity management, healthy diet and regular physical activity.^{61,63,64,65,66}
• Vaccinations: Human papillomavirus (HPV) vaccine prevents cervical carcinoma and other HPV-related malignancies. Screening and vaccination for Hepatitis B in OPWH as well as early treatment initiation can prevent hepatocellular carcinoma.^61,67,68,69

Managing cancer in OPWH includes:

• Coordinate ART and oncotherapy: Assess and manage potential drug interactions between ART and cancer treatments (chemotherapy, targeted therapy, etc.).
• Monitor immunotherapy use: Evaluate the safety and efficacy of immunotherapy in the context of HIV, considering immune status and response.
• Address age-related toxicity: Monitor and manage increased treatment-related toxicity as a result of age, especially in older patients with HIV.
• Track immune and viral status: Regularly monitor CD4 cell counts and HIV viral load, as these may influence cancer treatment choices and outcomes.
• Manage comorbidities: Assess and manage cardiovascular and kidney disease, which can affect cancer treatment decisions and patient tolerance.^70,71

Palliative and end-of-life care

Palliative care

Palliative care aims to enhance the quality of life for patients and their families who have been diagnosed with life-threatening illnesses. Ageing accompanied by certain incurable diseases should necessitate the transition to a palliative care approach. Determining when a condition becomes life-threatening is complex and depends on patient-specific factors such as age, disease-specific factors such as the stage of the disease, and clinical context or available resources. The SPICT-SA tool⁷² (see Box 4) can assist in identifying when a condition reaches this stage. Palliative care can be provided alongside curative treatments.

Practical steps for clinicians implementing a palliative care approach include:

• Formation of a multidisciplinary team: This team may include social workers, healthcare professionals, rehabilitation practitioners, doctors, and nurses.
• Early communication with the patient and family: Early in the disease, patients and their families should be well-informed regarding the diagnosis and prognosis.
• Family involvement: The family is an integral part of the management process and should be empowered through education and counselling, with family meetings from an early stage.
• Advance care planning: This is a critical component of the palliative care approach. This process provides an opportunity to explore the patient’s fears, goals of care, and future care needs. These should be documented but remain flexible and open to revision.
• Management of physical symptoms: Anticipation and treatment of physical symptoms are vital. Common symptoms include pain, weight loss, confusion, and constipation.⁷³
• Management of medications: When treating elderly patients, medications, particularly opioids, must be initiated at low doses and increased gradually, to minimise side effects. For more information see Chapter 22 of the Standard Treatment Guidelines for Primary Health Care (Box 4).³⁵
• Addressing social concerns: Social issues such as loneliness, future care and financial constraints must be discussed. Families should be screened for other vulnerable dependents who may rely on the patient.
• Support for psychological well-being: Psychological symptoms, including anxiety and fear, should be managed through social care, support groups, and open discussions about the patient’s concerns.
• Provision of spiritual care: Spiritual support should explore patients’ sense of meaning, purpose, and legacy.
• Linking to resources: Link patients and families to community resources such as Home Base Care organisations, Hospice and Dementia support (see Box 4).

End-of-life care

End-of-life care is provided when patients are in their final weeks or days of life. At this stage, management should change, and an end-of-life care approach should be followed:

• Inform the family and patient that you are ‘concerned’ that the end ‘may’ be near. Avoid giving an exact timeframe.
• Rationalise all medications, such as statins (and possibly including ART), and discontinue interventions such as regular blood tests.
• Prescribe medication to address anticipatory symptoms, including pain, secretions, nausea, vomiting, and delirium.
• All interventions should prioritise comfort.
• Regular repositioning and oral care are essential.
• Nutrition should focus on comfort feeding, and the use of nasogastric tubes is not recommended.
• Provide the family with clear guidelines on what to do before, during and after the patient passes away.
• Link the family to bereavement support services.

Conclusion

Ageing with HIV presents unique clinical challenges, including more comorbidities, polypharmacy, and an increased risk for geriatric syndromes such as frailty and cognitive impairment. These issues are further complicated by potential DDIs between ART and medications commonly used to manage age-related conditions. On the other hand, PWH are ‘in care’ and are relatively frequently encountered in the health system. Integrating geriatric assessments in a systematic and relatively pain-free manner may reduce unnecessary morbidity and improve ‘health span’ as well as ‘life span’ in OPWH. Integrating HIV care with geriatric principles can preserve functional independence and improve quality of life. A broader perspective of the needs of OPWH will be vital in ensuring that ageing PWH receive safe, effective, and compassionate care.

Acknowledgements

The authors, Nomathemba Chandiwana, Jeremy S. Nel, W.D. Francois Venter, Camilla Wattrus, and Linda-Gail Bekker serve as editorial board members of this journal. The other authors have no other competing interests to declare.

Evan Shoul: Writing – original draft, writing – review & editing. Nomathemba Chandiwana: Writing – original draft, writing – review & editing. Sathya Jogulu: Writing – original draft. Rene Krause: Writing – original draft. writing – review & editing. Coceka Mnyani: Writing – original draft, writing – review & editing. Zainab Mohamed: Writing – original draft, writing – review & editing. Jeremy S Nel: Writing – original draft, writing – review & editing. Sam Nightingale: Writing – original draft. Catherine Orrell: Writing – original draft. W.D. Francois Venter: Writing – original draft. Camilla Wattrus: writing – original draft, project administration, writing – review & editing. Linda-Gail Bekker: writing – original draft, writing – review & editing, supervision. All authors reviewed the article, approved the final version for submission and publication, and take responsibility for the integrity of its findings.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data sharing is not applicable to this article as no new data were created or analysed.

The views and opinions expressed in this guideline are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. To the fullest extent permitted by law, the Southern African HIV Clinicians Society (SAHCS) and the authors of this guideline cannot be held liable for any aspect of healthcare administered using this information or any other use, including any use that is not in accordance with any guidelines or (mis-)use. Specific recommendations provided here are intended only as a guide to clinical management based on expert consensus and best current evidence at the date of first publication. Management decisions for clients should be made by their responsible clinician/s, with due consideration for individual circumstances and various contexts. The information provided in this guideline should not be considered as a substitute for such professional judgement. The most current version of the guideline should always be consulted.

References

Appendix 1