From survival to healthy aging: reframing HIV care for older adults

Abstract

BACKGROUND: Effective antiretroviral therapy (ART), has transformed HIV into a chronic condition, enabling more people with HIV to reach older age. However, longevity has exposed a growing burden of multimorbidity, frailty, functional decline, polypharmacy, and age-related syndromes that are not adequately addressed by ART-centered care models. AIM: This review reframes HIV care for older adults by synthesizing evidence on biological aging, multimorbidity, geriatric syndromes, pharmacological challenges, and care-system responses in high-income and low- and middle-income settings. METHOD: This narrative review synthesizes current evidence on HIV, aging, and multimorbidity, focusing on biological, clinical, and socio-cultural dimensions. Literature searches were conducted in PubMed, Scopus, and Web of Science up to August 2025 using relevant keywords. Priority was given to large cohort studies, randomized trials, and systematic reviews. RESULTS: Aging with HIV is driven by chronic immune activation, inflammaging, immunosenescence, mitochondrial dysfunction, epigenetic aging, cumulative ART exposure, and social determinants. These processes contribute to interconnected cardiovascular, metabolic, renal, bone, neurocognitive, malignant, and mental health conditions. Geriatric syndromes such as frailty, sarcopenia, falls, sensory impairment, and polypharmacy further complicate care, with greater challenges in low- and middle-income countries (LMICs) due to infectious comorbidities, limited diagnostics, weak geriatric services, and restricted access to essential medicines. CONCLUSION: HIV care must evolve beyond viral suppression to integrated, age-friendly, context-sensitive models that combine ART with multimorbidity screening, medication review, functional assessment, mental health support, and equitable policies for healthy aging.