Ageing with HIV

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The efficacy of antiretroviral therapy (ART) and the success of global treatment programmes has meant that, provided individuals have access to care, HIV infection is no longer a life-limiting infection. However, with this success comes unexpected consequences: a growing population of older people with HIV (normally defined as those aged 50 years or older). This population is increasing because young people with HIV are surviving and ageing, and an increasing number of older people are acquiring HIV. Consequently, prevalence and incident infections in people aged 50 years and older are increasing at a faster rate than in the population as a whole; for example, in the USA, between 2015 and 2019, the overall prevalence of people with HIV infection increased by 8% and incident infections decreased by 4%, whereas in people aged 50 years and older, prevalence increased by 40% and incidence by 15%. UNAIDS estimates that the number of people aged 50 years or older with HIV infection globally increased from 5·4 million in 2015 to 8·1 million in 2020. In this issue, we publish a joint Series with The Lancet HIV on the challenges of ageing well with HIV. We address four important topics: the geroscience underlying the high multimorbidity burden in older people with HIV; intersectionality of stigma and health-related quality of life; delayed HIV presentation; and how health systems can adapt to a population ageing with HIV and comorbidities. We hope this Series, discussed alongside The Lancet Summit on HIV and Healthy Longevity (March 17–18, 2022, virtual), will stimulate debate between geriatricians, geroscientists, infectious disease specialists, and those living and ageing with HIV. Older people with HIV face unique challenges. Older people are widely perceived by society, including by health-care professionals, to be less at risk of contracting new HIV infections. Because society assumes that older people are not sexually active or drug users, there are barriers to access to protective health information and early HIV testing. Consequently, nearly half of older adults with HIV are diagnosed late in the course of their disease (defined as having CD4 cell counts <350 cells per μL, or an AIDS-defining event). In their Series paper, Amy Justice and colleagues use data from the International epidemiology Databases to Evaluate AIDS (IeDEA) global consortium to identify the factors associated with late HIV presentation in older adults. Older people are more likely than younger people to have multiple comorbid conditions (multimorbidity). However, older people with HIV also have higher levels of multimorbidity compared with people of similar age without HIV. There is a considerable research gap in understanding how HIV affects the ageing process. In their paper, Monty Montano and colleagues examine biological ageing with HIV from a geroscience perspective to examine whether the major hallmarks of ageing might act synergistically with an HIV infection to become gerodrivers in people with HIV. In addition to higher levels of multimorbidity, older adults with HIV also face stigmatisation. In their paper, Evelyn Hsieh and colleagues discuss how people ageing with HIV face an intersection of age-related and HIV-related stigma, which has a traumatic impact on their health-related quality of life. The authors reviewed intersectionality of these stigmas in China, Europe, and Latin America, which have distinct epidemiological and cultural trends in ageing and HIV incidence, and found a paucity of evidence and inconsistent use of frameworks, especially in Latin America, which might impede provision of care and appropriate policy and research. Finally, health-care systems globally are not equipped to meet the needs of the growing population of older people with HIV. Health-care systems provide fragmented care to older people with HIV, worsened by the lack of integrated ageing and HIV-related service and support systems. In their paper, Jepchirchir Kiplagat and colleagues propose how health care could be improved through a responsive universal health coverage approach. Even an ideal world that achieves the UNAIDS 95-95-95 goal will continue to have a growing population of older people who will need appropriate care. As such, there is arguably a need for a new research area to understand how chronic but ART-suppressed HIV infection interacts with the ageing process—and if this understanding can inform our knowledge of basic ageing mechanisms. The need for this research is the result of the success of ART: we must continue to build on that success to ensure that ageing with HIV is something to be celebrated, not mourned.