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.
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.
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,
Integrated care for older people (ICOPE) five-step pathway for managing intrinsic capacity.
The management of OPWH requires a fundamental shift from a singular focus on HIV virology and the management of a viral infection to a person-centred, multidisciplinary approach that integrates HIV care with geriatric medicine principles.
To enable effective task-shifting and cadre-appropriate care, ICOPE’s five-step pathway can be applied as a structured implementation framework:
ICOPE, integrated care for older people; IC, intrinsic capacity; HCW, healthcare worker.
HIV and the associated chronic immune activation may accelerate the ageing process, leading to an earlier onset of age-associated comorbidities.
Definition of geriatric syndromes.
A geriatric assessment provides a complete view of a patient’s function, cognition and health, and improves prognostication and treatment decisions.
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
Specific challenges faced by older people within the HIV continuum of care.
| Physiological | Social and behavioural | Structural/health system |
|---|---|---|
Suboptimal immunological response to ART. Some ARVs increase risk of certain NCDs. Increased risk of comorbid conditions (e.g. hypertension, cancer). Increased risk of polypharmacy and its complications, including increased risk of poor adherence, adverse events and DDIs |
Perceived low risk of HIV acquisition. Low rates of HIV testing. Low rates of condom use. Low rates of HIV PrEP uptake. Adherence challenges. Continued engagement in risky behaviours. Limited social support. |
HCWs unaware of HIV risk among older individuals. Limited availability of differentiated HIV prevention and treatment services. Lack of access to services for non-HIV conditions. Limited mobility restricting access to services. Increased risk of poverty resulting from lack of income. |
ART, antiretroviral therapy; ARVs, antiretrovirals; NCDs, non-communicable diseases; DDIs, drug–drug interactions; PrEP, pre-exposure prophylaxis; HCWs, healthcare workers.
An approach to ageing in HIV care should include
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 OPWH
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.
Screening, prevention, and counselling recommendations for older people with HIV.
| Domain | Frequency | Note | Recommended cadre |
|---|---|---|---|
| Every visit | Review of all prescribed, OTC and traditional medications. Ask specifically about calcium, magnesium, iron and St John’s wort, as these can reduce dolutegravir levels. Deprescribe unnecessary medications. Ensure ART is optimised. Check for DDIs using a drug interaction checker (see |
CNP or doctor (nurse may conduct initial review; deprescribing and DDI management requires CNP or doctor) |
|
| Annually | Screen for harmful alcohol use using AUDIT-C questionnaire (see Actively counsel on smoking reduction or cessation and alcohol use. Use a harm-reduction approach. |
Any trained HCW |
|
| Annually and opportunistically when clinically indicated | Ask about mood, anxiety, functional impairment, and suicide risk. Screen using PHQ-2 and GAD-2 questionnaires for case finding. If positive, proceed to PHQ-9 and GAD-7, and manage actively. See |
Any trained HCW (screening); CNP or doctor (management) |
|
| Every visit | Ask about current activity level, physical activity, sedentary time, mobility limitations, pain and history of falls. Ask about difficulty walking or rising from a chair. Encourage reducing sedentary time; any movement is better than sitting, even light activity. If able, aim for at least 150 min or week of moderate activity (e.g. brisk walking), or shorter periods of more vigorous activity. Do strengthening exercises at least twice a week. Include activities that work legs, hips, arms and core. Add balance and functional exercises at least three times a week, especially if risk of falls. |
Any trained HCW |
|
| Every visit | Ask about problems with memory and orientation (e.g. recall, date or place). If present, examine. |
Any trained HCW |
|
| Biannually | Ask about sleep quality, insomnia symptoms, snoring or sleep apnoea, daytime sleepiness. Screen for OSA with STOP-BANG; sleepiness with Epworth Sleepiness Scale (see Assess and address contributors: mood, pain, substances, ART timing or agents, other medications. Counsel on basic sleep hygiene. |
Any trained HCW (screening); CNP or doctor (management) |
|
| Every visit | Ask about unintentional weight loss and reduced appetite. If present, refer for investigation and to dietician for nutritional support, as needed. |
Any trained HCW |
|
| Every visit | Ask about difficulty hearing or following conversations, and perform Whisper test. |
Any trained HCW (whisper test); refer to audiologist if abnormal |
|
| Every visit | Ask about difficulty seeing (even with glasses). |
Any trained HCW; refer to optometrist if abnormal |
|
| Biannually | Ask about sexual function and libido. Provide contraception as needed. Screen for STIs. If present, examine and manage (see |
Any trained HCW (history); nurse or CNP or doctor (examination and management) |
|
| Biannually | Ask about presence and severity. If present, review medication, perform genitourinary examination, and do appropriate blood and urine tests. |
Any trained HCW (screening); nurse or doctor (examination and investigations) |
|
| Annually | Assess social support. |
Any trained HCW; refer to social worker as needed |
|
| Annually | Ask about falls in the past year. |
Any trained HCW |
|
| Annually | Discuss safe driving especially if vision, mobility or cognition problems. If problems, recommend stopping driving. |
Any trained HCW; CNP or doctor if concerns about cognition, vision or mobility |
|
| Every visit | If on antihypertensives or reports dizziness, assess for orthostatic hypotension (low BP on standing) |
Any trained HCW |
|
| Annually | If unintentional weight loss (> 10% per year), assess for sarcopenia, frailty and cancer. |
Any trained HCW; dietician |
|
| Annually | Assess gait and balance. Perform chair-rise test. Screen for frailty using FRAIL scale ( |
Any trained HCW (FRAIL scale); nurse or CNP (gait, balance, chair-rise test) |
|
| If symptomatic | Screen functionality with IQCODE, or Barthel or Lawton functional assessments. If memory loss or functional decline, assess using MoCA or MMSE. MMSE may be more practical than MoCA (which is not locally validated) but must be interpreted with education level or cultural setting. Perform additional executive function testing if required. See |
Nurse or CNP or doctor (choice of test requires expertise; see text); specialist referral if needed |
|
| 6-monthly | Monitor eGFR. Monitor more frequently if on TDF or with known CKD. |
Nurse or CNP or doctor (ordering and interpretation) |
|
| Once | Take history of fractures or risk factors. Calculate FRAX score using online calculator (see Do DEXA scan in all women > 65 years and men > 70 years, or earlier if high fracture risk based on FRAX score. |
Nurse or CNP or doctor (FRAX); DEXA where available (specialist or radiology) |
|
| Annually | Do fasting lipid profile and manage accordingly. |
Nurse or CNP or doctor |
|
| Annually | Do fasting blood glucose or HbA1c, especially if BMI ≥ 25, hypertensive, or hyperlipidaemia. |
Nurse or CNP or doctor |
|
Any trained HCW |
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HCW, healthcare worker; CNP, clinical nurse practitioner; OTC, over-the-counter; ART, antiretroviral therapy; DDIs, drug–drug interactions; AUDIT-C, alcohol use disorders identification test-consumption; PHQ-2, patient health questionnaire-2; GAD-2, generalised anxiety disorder 2-item; PHQ-9, patient health questionnaire-9; GAD-7, generalised anxiety disorder 7-item; OSA, obstructive sleep apnoea; STIs, sexually transmitted infections; SAHCS, Southern African HIV Clinicians Society; BP, blood pressure; BMI, body mass index; IQCODE, informant questionnaire on cognitive decline in the elderly; MoCA, Montreal cognitive assessment; MMSE, mini-mental state examination; eGFR, estimated glomerular filtration rate; TDF, tenofovir disoproxil fumarate; CKD, chronic kidney disease; FRAX, fracture risk assessment tool; DEXA, DEXA bone density scan; HbA1c, haemoglobin A1c.
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
Immunisation recommendations in older people with HIV.
| Vaccine | Who | When |
|---|---|---|
All (especially if chronic lung disease), regardless of CD4 or HIV viral load. |
Seasonal: annually between March and May. Pandemic: as required. |
|
All, if not vaccinated. Can be given if CD4 < 200 cells/µL if on ART with suppressed VL. Poor response if CD4 < 200 cells/µL and VL not suppressed. |
Give PCV13 followed 8 weeks later by PPV23. Give booster after 5–10 years. Maximum 2 booster doses, or 1 booster dose if > 65 years. |
|
All ≥ 50 years old, if not vaccinated and resources allow. |
Give 2 doses 2–6 months apart. |
|
If new grandchildren, pregnant family member/household contact |
Give single dose Give booster every 10 years. |
|
If HBsAg negative |
Give 3 doses Give dose 1, then dose 2 at 1 month after dose 1, then dose 3 at 6 months after dose 1 |
Note: At time of publication, the live vaccine (Zostavax®) is avaliable in public and private sectors but will soon be discontinued. Recombinant, aduvant vaccine (Shingrix®) will soon be registered in South Africa and is currently available through section 21 application.
PSV23, Pneumococcal Polysaccharide Vaccine; PCV13, pneumococcal vaccine 13-valent; ART, antiretroviral therapy; VL, viral load; HBsAg, Hepatitis B surface antigen
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 (
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:
For more details on selecting a first-line regimen, opportunistic infection prophylaxis, and renal disease, see
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:
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.
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 (
FRAIL questionnaire.
Manage frailty as follows:
Useful resources for clinicians.
ICOPE handbook: Integrated care for older people (ICOPE): guidance for person-centred assessment and pathways in primary care, 2nd edn
DementiaSA:
Home Base Care organisations and Hospice support:
Liverpool website to check DDIs:
PHQ and GAD questionnaires: Generalized Anxiety Disorder 2-item (GAD-2) - Mental Health Screening – National HIV Curriculum
SPICT-SA tool: Version-2-SPICT-SA.pdf
STOP-BANG Questionnaire: The Official STOP-Bang Questionnaire Website
Epworth Sleepiness Scale: Epworth Sleepiness Scale (ESS) Screening Tool | Sleepcountshcp
AUDIT-C questionnaire: Form: AUDIT-C Questionnaire
FRAX score online calculator:
Framingham score:
FRAIL questionnaire :
Tools for cognitive testing:
Montreal Cognitive Assessment (MoCA): | MoCA Test Mini Mental State Examination (MMSE): Mini-Mental State Exam (MMSE) Test for Alzheimer’s / Dementia Addenbrooke’s Cognitive Examination (ACE-III):
Southern African HIV Clinicians Society guidelines:
Sexually transmitted infections: SAHCS 2022 STI guidelines.pdf (SECURED) Syphilis: SAHCS syphilis guideline.pdf ART: Southern African HIV Clinicians Society PrEP: SAHCS PrEP guideline 2025.pdf
SA National Department of Health guidelines:
Consolidated ART guidelines: National Consolidated Guidelines 04-03-2026.pdf Standard Treatment Guidelines for Primary Health Care (STG/EML): PHC-Standard-Treatment-Guidelines-and-EML-8th-Edition-2024.pdf National Guidelines on the Treatment of Tuberculosis Infection: Health_Latent%20TB%20Infection_2023_web.pdf Clinical Management of Rifampicin-Resistant Tuberculosis: Updated RR-TB Clinical Guidelines September 2023.pdf
Polypharmacy is the use of ≥ 5 medications. It is common among OPWH and a major driver of adverse drug events, non-adherence, and hospitalisations.
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 (
Taper and stop any non-essential medications and where risks outweigh benefits.
Simplify prescribed medication by using combination pills (e.g. single-pill ART, fixed-dose combinations) to reduce pill burden.
HIV itself may cause cognitive impairment and OPWH are at higher risk for all-cause dementia.
Causes of brain injury in people living with HIV.
| HIV-associated brain injury (HABI) | Other causes of brain injury |
|---|---|
Legacy HABI: Inactive brain injury from pre-ART damage. Active HABI: Ongoing brain injury leading to clinical or radiological progression |
Neurological causes:
Neurodegenerative disorders (e.g. Alzheimer’s disease) Cerebrovascular disease Developmental disability Traumatic brain injury Non-HIV related neurological conditions (e.g. multiple sclerosis or uncontrolled epilepsy) Nutritional deficiencies (e.g. vitamin B12) Infection related:
CNS infections (e.g. TB, cryptococcosis, neurosyphilis) Coinfections (including syphilis and hepatitis C) Toxin related:
Hazardous alcohol use Substance misuse Antiretroviral CNS neurotoxicity (e.g. efavirenz) |
HIV, human immunodeficiency virus; HABI, HIV-associated brain injury; ART, antiretroviral therapy; CNS, central nervous system; TB, tuberculosis.
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
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
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
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.
Avoid sedatives and anticholinergics including tricyclic antidepressants.
If needed, offer information and practical support.
It is important to screen OPWH for fall risk. Use a simple physical performance test such as:
Timed-Up-And-Go (TUG) Ask the patient to stand up from chair, walk 3 m, turn, walk back and sit down.
5 times sit to stand (5 x STS) Ask the patient to sit on chair, fold their arms, stand up and sit down five times.
Evaluate for causes of fall risk including:
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.
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.
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.
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.
Always assess for suicidal ideation in patients with depression. This is a psychiatric emergency that if present requires immediate referral.
Management includes
For more information see Chapter 16 of the National Standard Treatment Guidelines for Primary Health Care (
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.
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
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.
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 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 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 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.
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
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
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 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.
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
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.
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 disease
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:
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.
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.
Sleep disturbances are common in OPWH and significantly impact mental health, neurocognitive functioning, cardiometabolic risk and overall functional status.
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 (
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.
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 (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.
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.
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.
Screening for malignancy is essential in OPWH because of increased cancer risk from ageing, longer survival on ART, and premature ageing in PWH.
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).
Strategies to reduce cancer risk include:
Managing cancer in OPWH includes:
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 tool
Practical steps for clinicians implementing a palliative care approach include:
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.
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.
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.
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.
Cancer screening recommendations in older people with HIV.
Women over 40 years in the public sector: annual clinical breast examination, breast self-examination, awareness campaigns. Average risk women 40–75 years old who are asymptomatic in the private sector: mammogram, ultrasound or MRI as appropriate every 2nd year from age 40 years. Discontinue mammography screening for women older than 75 years. Women at high risk for breast cancer (e.g., family history): mammography screening at specialised breast clinics in both public and private sectors. Cervical screening in the public sector depends on geographic location. Pap smear is used most frequently but liquid-based cytology (LBC) and Human papillomavirus (HPV)-based screening to be phased in. Sexually active women living with HIV regardless of age:
Conventional cervical cytology (Pap smear) every 3 years if last screening was normal. Screen annually if last screening was abnormal. Stop screening after 50 years if 2 consecutive negative screening tests. Areas with significant resource constraints still practice visual inspection with ascetic acid (VIA). Men > 50 yrs old who are asymptomatic, with a life expectancy > 10 years: Prostatic-specific antigen (PSA) screening with intervals depending on the first PSA result.
Black African men or those with a first degree relative with prostate or breast cancer: commence PSA screening at 40–45 years. Discontinue screening in asymptomatic men > 70 years. Digital rectal examination (DRE) only in symptomatic men or if PSA is elevated PSA reference range increases with age. PSA ≤ 4 ng/mL is acceptable. Defer PSA testing if prostatitis, acute urinary retention, urethral instrumentation or trans-urethral resection of the prostate (TURP). Repeat if PSA is elevated but < 10ng/mL in asymptomatic men with a normal DRE. Do free/total PSA to improve specificity of cancer diagnosis if PSA elevated but < 10 ng/mL. SA public sector: PSA screening is not routinely done; do PSA and DRE in symptomatic men. Men-who-have-sex-with-men (MSM) with HIV from 35 years, and men and women with HIV from 45 years: annual digital ano-rectal examination (DARE). International standard of care: DARE plus cytology and high-risk HPV testing. Average risk: screen from 45 years if life expectancy > 10 years and continue screening until 75 years. Faecal immunochemical test (FIT) has replaced faecal occult blood (FOB) test: to be done annually.
A positive FIT or FOB must be followed by colonoscopy. Screening colonoscopy intervals determined by findings at first colonoscopy. In the public sector colonoscopy screening is only offered at specialised units to individuals with a genetic predisposition or positive family history. Persons with cirrhosis: 6-monthly ultrasound of hepatobiliary system and serum alpha fetoprotein (AFP) at specialised units in public sector. |