From ‘life span’ to ‘health span’ – new guidelines for ageing with HIV in South Africa

New clinical guidelines for the care of older people with HIV shift the focus from viral suppression to overall health. As the world’s population of people over 50 years old living with HIV grows, it becomes increasingly important to understand how HIV and geriatric medicine interact.

The Southern African HIV Clinicians Society recently released its first clinical guidelines for the management of older people with HIV in the Southern African Journal of HIV Medicine. Although the care of older patients is included in some other guideline documents, this is the first advice of its kind in an African context.

Due to the availability of antiretroviral therapy (ART), HIV is now “a chronic, easily manageable condition”, as the guideline publication states, with a longer life expectancy than before. This means the elderly population of people with HIV is set to grow in the next few decades, particularly in Africa.

Specifically, people over the age of 50 are now South Africa’s second largest population with HIV, while it was the smallest in 2010, according to data analysis by local health news outlet Bhekisisa. In light of this, the guidelines come at a critical time as clinicians are faced with a new set of challenges. 

Crucially, older people with HIV are at higher risk for certain age-related complications. The experts write that people with HIV may experience ‘accelerated’ or ‘premature’ ageing – they may have a higher burden of non-communicable diseases (NCDs), geriatric syndromes, and social isolation at an earlier age than people without HIV. The researchers put this down to conventional age-related risks being escalated by chronic inflammation caused by HIV and the long-term effects of ART.

Polypharmacy, meaning the problematic use of more than five medications concurrently, is another common challenge.

Thus, the guidelines look beyond viral suppression as a key factor for health. They use the WHO Integrated Care for Older People (ICOPE) framework’s measures of intrinsic capacity. This includes locomotion, vitality, vision, hearing, cognition, and psychological well-being, which should be checked at regular health visits.

Managing HIV itself is, understandably, still a cornerstone of the guidance. This means that ART should be optimised according to the other risk factors and age-related co-morbidities someone has. For example, tenofovir disoproxil fumarate (TDF) is contraindicated for those with a high risk of bone fractures, osteoporosis or renal impairment. Instead, a tenofovir alafenamide (TAF)-based combination therapy is more favourable.

Following on from this, older patients with HIV should be monitored carefully for ART side effects or drug-on-drug interactions. The list of monitoring needs includes weight changes, renal function, and mental health.

The document was written by 12 renowned HIV experts from various hospitals and institutes, including the University of Cape Town and the University of the Witwatersrand. They notably focus on offering care for older persons with HIV in lower- and middle-income countries (LMICs). In the South African context, there is an increased risk of poverty influencing access and use of care services. Older patients may also struggle with limited mobility, which can restrict their access to services.

The guidelines take a holistic approach to caring for people ageing with HIV. For example, they suggest discussing ageing while having HIV with the patient, so as to “help identify medical priorities and evaluate physical function.” This foregrounds education around these issues and a collaborative, multidisciplinary approach.

The guidelines appear targeted towards clinicians who may not have engaged with the issue thoroughly before, perhaps due to unawareness or stigma. It suggests “becoming familiar with the available screening tools, and local and national services for older people.”

Another suggestion is that clinicians help by “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.”

Another point in the guidelines particularly speaks to how task-shifting and cadre-appropriate care can be key in resource-constrained settings. For instance, the ‘Friendship Bench’ model of peer-led community mental health support is a task-shifted, effective strategy. Many of the integrated care strategies, like screening and developing a care plan, can be undertaken by a number of different healthcare workers. They also encourage a multidisciplinary approach, including other professionals like a dietitian and social worker, to make the most of the available resources.

The guidelines outline a minimum recommended screening schedule for this group of patients. Every medical visit includes checks of medication, cognition, vision and more, thus keeping an eye on frailty, polypharmacy and other risks. Biannual visits might include a screening of sleep problems, sexually transmitted infections and renal function. Meanwhile, annual visits focus on issues like social support, frailty and lipids.

The experts recommend a variety of strategies to prevent and manage comorbidities, particularly non-communicable diseases (NCDs) like diabetes and hypertension. In their recommendations for cardiovascular disease (CVD), they focus on calculating and modifying risk, as well as interventions that mirror a general population approach. It is notable that there is no mention of offering statins from a younger age, which most high-income countries tend to do. 

Guidelines elsewhere touch on similar issues but are often less comprehensive. Advice from European and American guidelines seems to focus on managing particular conditions, rather than on improving health in a holistic way, without consideration of the LMIC context.