For decades, public health efforts across sub-Saharan Africa have focused on HIV prevention, testing and treatment campaigns on children, and women of reproductive age, overlooking the population at older ages.

At present, the high success of antiretroviral therapy (ART) campaigns, together with the continuous efforts to achieve the UNAids 95-95-95 HIV targets – that 95% of people with HIV know their status, 95% of those are on treatment, and 95% of those have suppressed viral loads – have reduced the HIV treatment gap in many African countries. In turn this has dramatically increased the life expectancy of people living with HIV.

One consequence of this is that the HIV epidemic is increasingly affecting older people. Due to this increase in life expectancy in the population living with HIV, the HIV epidemic has experienced an ageing process.

However, most HIV programmes and studies still neglect the population over 50 years of age. The immediate consequence is that older adults, especially women past childbearing age, are often invisible in surveillance data, overlooked in prevention messaging, and under-represented in care strategies.

Few HIV interventions are tailored to this group, even though they face unique risks. This blind spot has serious consequences for the health and well-being of a growing and vulnerable population.

We have worked in the past years to better understand the ageing process of the HIV epidemic, not only on the growing number of people living with HIV, but also on explaining the risks of new HIV infections in the older population.

In response to this dearth of data, we studied the changes in the HIV epidemic in a group of older people over two waves of data collection (2013-16 Wave 1; 2019-22 Wave 2) and across nearly a decade.

The study, a sub-study of the AWI-Gen study in Africa, followed over 7,000 adults aged 40 and older in four locations. Three were in South Africa – the urban setting of Soweto in the country’s industrial heartland and the rural setting of Bushbuckridge in the north-east of the country, and Dikagale, Mamabolo and Mothiba in the north – and one in Nairobi slums in Kenya.

These settings allow for comparison of east and southern Africa, the two African regions with higher prevalence of HIV. At the same time, it permits a comparison between rural and urban settings.

We were able to assess the number of people living with HIV, the number of new infections, and the social factors driving the HIV transmission. We did this by doing HIV tests and asking participants if they’d ever been tested for HIV, whether they knew their HIV status, and whether they were receiving ART.

We found that one in five adults (22%) in the study were living with HIV (that is, they were infected with HIV). This rate stayed high across both time points. We also observed that new infections were happening in this older population, especially in widows, rural residents and those with no formal education.

This shows that, even as treatment access improved, major disparities persisted. And older adults are still acquiring HIV, often because the public campaigns for HIV leave them out.

The conclusion that can be drawn from our findings is that the world needs to stop seeing HIV as only a “young person’s disease”. The narrative needs to change, as must the response. Ageing with HIV is now a global public health reality – especially in sub-Saharan Africa – and the HIV response must evolve to reflect that.

The myths putting older adults at risk

One of the most pervasive misconceptions we encountered is that older adults – especially those who are widowed or postmenopausal – are no longer at risk of HIV. Many believe that if you’re no longer at risk of pregnancy, you’re no longer at risk of infection.

As a result, condom use drops off, testing is delayed, and people start new relationships later in life without knowing their partner’s status.

There’s also stigma. Older adults grew up during a time when HIV was associated with silence and shame. Many feel deep embarrassment or fear about getting tested, disclosing their status, or even discussing sexual health with healthcare providers. Some simply don’t believe it could happen to them.

In our first wave, only 55% of people who were HIV-positive correctly self-reported their status. The effect is delays in treatment, increased transmission risk, and undermining of public health planning.

On a positive note, we observed an increase of correct self-reporting to 77% in the second wave, which may improve ART coverage and viral suppression in older population in the future.

Factors driving infection rates

One of the strongest protective factors we found was formal education. Older adults with no formal schooling were almost four times more likely to acquire HIV than those with secondary education or higher. Education improves health literacy, empowers people to seek care, and enhances understanding of HIV transmission and prevention.

Similarly, people living in rural areas – especially women – had higher rates of HIV than their urban counterparts. These are not simply behavioural differences. They reflect systemic inequalities: limited access to testing, healthcare shortages, low levels of targeted prevention messaging, and deeply embedded stigma.

Being married, employed, or economically secure were also associated with lower risk – reinforcing that HIV risk among older adults is shaped as much by social structures as by individual behaviour.

What needs to change

As older people age with HIV, they are increasingly living with other chronic conditions like diabetes, hypertension, or arthritis. Yet, healthcare systems often treat these conditions in silos. An older person may have to visit the same clinic on different days or reach different health facilities to receive HIV medication, hypertension and diabetes treatment, and mental health support – if they have access to all three.

The health structures and policy makers need to develop more integrated, age-friendly care services. Among other interventions, this would mean:

  • offering routine HIV testing to adults over 50

  • integrating HIV services with screening for non-communicable diseases

  • training healthcare providers to address the specific needs and lived realities of older adults

  • investing in stigma-free, culturally appropriate health messaging that includes and empowers older people.

There are already promising models in some African settings, such as community health workers delivering medication and conducting health checks in one visit, or peer-support groups for older adults living with HIV, and integration of HIV and noncommunicable diseases in primary healthcare systems. There are examples of this in some areas in South Africa. But they remain minimal and underfunded. Scaling them up requires political will and financial commitment.

Why older adults matter for the 95-95-95 goals

If older adults aren’t included in managing the HIV pandemic, the UNAids 95-95-95 targets will not be met. And the risks of inaction are growing.

As international HIV funding comes under pressure, including cuts to Pepfar and other global programmes, it is often the most marginalised who are hit hardest. That includes older women in rural villages who don’t think HIV applies to them, and who are left out of the testing lines. Pepfar (the US President’s Emergency Plan for AIDS Relief) has prevented millions of HIV infections, and has supported several countries to achieve HIV epidemic control.

It’s therefore time to rewrite the narrative.

The HIV response must reflect that older people are affected by the disease. That means investing in local research, designing age-inclusive services, and acknowledging that older adults have sexual lives, health needs, and rights. It also means listening to their stories and dismantling the myths that have kept them silent.

Ignoring this population risks reversing decades of progress. But action now – tailored services, inclusive messaging, and African-led innovation – can close the gaps, save lives, and build a more equitable HIV response for the future.

This article is republished from The Conversation, a nonprofit, independent news organization bringing you facts and trustworthy analysis to help you make sense of our complex world. It was written by: Francesc Xavier Gomez-Olive Casas, University of the Witwatersrand and Luicer Anne Ingasia Olubayo, University of the Witwatersrand

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The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.