In sub-Saharan Africa, HIV infections are escalating among the over-50s, particularly older women – numbers have doubled – yet prevention and treatment campaigns still focus mainly on younger people, according to data from the Africa Wits-INDEPTH Partnership for Genomic Research.
Ongoing research shows that older adults face comparable or higher infection rates but remain largely invisible in HIV studies, hampering progress toward global health goals. Persistent stigma, outdated perceptions, and limited education or access in rural areas worsen the situation, especially for older women.
Between 2000 and 2016, the number of adults aged 50 and older infected with HIV in sub-Saharan Africa doubled, and currently, their HIV prevalence is exceeding that of younger adults.
By 2040, one-quarter of people with HIV in Africa will be over 50 – so tailored awareness and treatment campaigns are urgently called for, says Dr Luicer Olubayo, a researcher at the Sydney Brenner Institute for Molecular Bioscience (SBIMB) at Wits University and the first author of a study published in The Lancet Healthy Longevity journal, which investigated HIV in older people in Kenya and South Africa.
He noted that perceptions on who acquires HIV are limited. “We often think of HIV as a disease of younger people, and it doesn’t help that intervention campaigns are mainly targeted at the youth.”
Moreover, older adults are less likely to believe they can get HIV. This misconception is pervasive and has consequences for reaching global targets to achieve the UNAIDS 95-95-95 targets by 2030.
“While HIV prevalence among over-50s is similar to or even exceeds that of younger adults, HIV surveys focus on younger individuals, leaving considerable gaps in understanding HIV prevalence, incidence and treatment outcomes in older populations,” said Associate Professor F. Xavier Gómez-Olivé, at the MRC/Wits-Agincourt Research Unit.
Stigma still a barrier to treatment
The uptake of HIV testing among older adults is poor, which delays diagnosis and limits access to care.
“We know there is significant social stigma related to HIV infection. This is why understanding that in older adults remains crucial as a way to inform interventions to support their mental health and overall well-being,” said Olubayo.
Interventions could focus on repeated testing, the use of pre-exposure prophylaxis (PrEP), and campaigns to increase awareness and reduce infections among the elderly.
“HIV can be managed alongside other chronic conditions, too, since HIV is managed as a long-term illness,” Gómez-Olivé said.
Non-communicable diseases, like hypertension, diabetes, and obesity, have dramatically increased in sub-Saharan Africa, particularly among older people. HIV treatment and intervention can be included in the healthcare ecosystem of long-term illnesses, the authors suggested
Complex interplay of factors
The study shows that age, education, gender, and where people live all affect their risk of HIV. Even though more people now have access to HIV treatment, older adults, especially in rural areas, still face challenges in preventing HIV, such as low education levels and gender inequality.
Widowed women had the highest HIV rate (30.8%). This may be due to losing a partner to HIV, stigma, and a greater risk of unsafe behaviours like transactional sex and limited power to negotiate condom use. People without formal education and those with low income also had higher rates of HIV infection.
Benefit of data to make decisions
An important added value of this study is the provision of longitudinal insights into the HIV epidemic among older adults in the region.
“With longitudinal data, we can look at the effectiveness of antiretroviral therapy coverage in older people,” says Gómez-Olivé.
The study used data collected in urban Kenya and in urban and rural sites across South Africa during two data collection waves: 2013-2016 and 2019-2022.
Data for the study were drawn from the Africa Wits-INDEPTH Partnership for Genomic Research (AWI-Gen) from adults aged 40 and older. AWI-Gen is a multicentre, longitudinal cohort study conducted at six research centres in four sub-Saharan African countries (South Africa, Kenya, Burkina Faso, and Ghana) to investigate various health determinants.
Study details
The prevalence, incidence, and sociodemographic risk factors of HIV among older adults in sub-Saharan Africa (AWI-Gen): a multicentre, longitudinal cohort study
Luicer A Ingasia Olubayo, Theophilous Mathema, Chodziwadziwa Kabudula, et al.
Published in The Lancet in March 2025
Summary
Background
Sub-Saharan Africa’s ageing population includes a rising number of adults aged 50 years and older living with HIV. Although antiretroviral therapy (ART) has extended life expectancy, data on HIV incidence and treatment outcomes among older adults remain scarce. To inform targeted public health interventions, we aimed to examine the prevalence and incidence of HIV, as well as sociodemographic determinants associated with HIV acquisition and treatment outcomes, among older adults in sub-Saharan Africa.
Methods
AWI-Gen is a multicentre, longitudinal cohort study. We assessed data from random community-based samples of adults aged 40–60 years collected between Aug 5, 2013, and Aug 19, 2016 (wave 1) and of adults aged 40 years and older collected between Jan 24, 2019, and Nov 23, 2022 (wave 2) from Nairobi (Kenya) and from Soweto, Agincourt, and Dikgale Mamabolo Mothiba (South Africa). Sociodemographic data were collected through interviewer-administered questionnaires and structured interviews. The primary outcome was HIV status at both wave 1 and wave 2, classified as either HIV-positive or HIV-negative. We evaluated the prevalence and incidence of HIV, ART coverage, and self-reported HIV awareness and used logistic regression to examine risk factors associated with HIV acquisition and treatment outcomes.
Findings
Among 7919 participants in wave 1 who were recruited and followed up, 6505 (82·1%) participants were aged 40–60 years, of whom 5730 (88·1%) contributed HIV-related data. 3148 (54·9%) participants were women and 2582 (45·1%) were men. In wave 2, 4520 participants from wave 1 were followed up with an additional 579 participants recruited. 5076 (99·5%) participants were aged 40 years and older, of whom 4931 (97·1%) contributed HIV-related data. 2767 (56·1%) participants were women and 2164 (43·9%) were men. Overall, 1271 (22·2%) of 5730 participants in wave 1 and 1073 (21·8%) of 4931 participants in wave 2 were living with HIV, with regional variability (χ2 p<0·0001) and higher prevalence in women than in men (χ2 p<0·0001). Prevalence was highest among individuals aged 40–45 years (454 [26·7%] of 1698 participants) in wave 1 and those aged 46–50 years (297 [29·9%] of 994 participants) in wave 2, decreasing significantly in older age groups (χ2 p<0·0001). Overall HIV incidence was 0·35 per 100 person-years (95% CI 0·26–0·48), with a reduced risk of seroconversion in participants aged 51–55 years (incidence rate ratio [IRR] 0·42 [95% CI 0·17–0·93]; p=0·039) and 56–60 years (0·19 [0·05–0·52]; p=0·0033). Compared with participants with formal education, incidence among those with no formal education was nearly four times higher (IRR 0·96 [95% CI 0·50–1·85] vs 0·26 [0·16–0·44]). Women and men residing in rural areas showed consistently higher predicted probabilities of HIV status than their counterparts in urban settings. The accuracy of self-reported HIV-positive status improved from 55·5% (95% CI 51·1–59·8) in wave 1 to 76·7% (73·1–80·0) in wave 2. ART coverage also increased between wave 1 (250 [90·3%] of 277 participants who reported a positive HIV test result) and wave 2 (404 [94·2%] of 429 participants).
Interpretation
The findings emphasise the complex interplay of age, education, gender, and location in shaping HIV risk. Although ART coverage has improved, older adults face considerable barriers to HIV prevention, including educational disparities and gender inequities, particularly in rural settings. Tailored interventions targeting older populations are essential to address these gaps because the risk of HIV acquisition, albeit generally lower than in younger populations, remains noteworthy.
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