An estimated 1.5m (29%) people with HIV were 50 and older – and the numbers are growing, according to The Lancet HIV Commission on Ageing’s 2026 report, highlighting how profoundly the global HIV epidemic is changing.
Writing in The Conversation, Luicer Anne Ingasia Olubayo and Francesc Xaviar Gomez-Olive Casa say this is projected to increase to 20.2m by 2040, and would account for more than half (51%) of all HIV+ people. Crucially, 96% will live in low- and middle-income countries, with Sub-Saharan Africa continuing to shoulder the greatest burden of the global HIV epidemic.
Much of this change reflects the success of antiretroviral therapy (ART), which has enabled millions of people who acquired HIV earlier in life to grow older. The challenge has gone beyond helping people live longer, to ensuring they age well – that they maintain good health, independence and quality of life throughout older age.
And although older adults are also acquiring HIV and being diagnosed later in life, prevention and testing campaigns remain focused on younger people.
Older adults are often assumed to be at low risk because of the misconception that they are no longer sexually active. Healthcare workers may be less likely to discuss sexual health, recommend testing or offer prevention options like PrEP. Moreover, older people may not see themselves reflected in HIV messaging that’s directed to younger people.
These assumptions contribute not only to delayed diagnosis and treatment, but also to discrimination within healthcare, where opportunities for prevention and early detection may be missed.
African context
Our recent Lancet Healthy Longevity Study, using data from the Africa-Wits Indepth Partnership for Genomic Research (AWI-Gen), provides an important longitudinal (long-term) African perspective that reinforces The Lancet Commission’s message.
We analysed data from more than 7 000 adults 40 and older in Kenya and South Africa, including rural and urban populations. The data were collected in 2013-2016 and 2019-2022. Data like these help us examine what is changing over time: whether treatment outcomes are improving, and which groups remain overlooked.
Our findings also show that older adults are not one uniform population. HIV risk was shaped by gender, education, socioeconomic circumstances and place.
Widowed women had the highest HIV prevalence, at 30.8%. This may reflect economic insecurity and persistent gender inequalities that continue to influence HIV vulnerability later in life. Prevention must respond to these gendered and social realities.
Stigma and ageism compound the problem. The perception that HIV is a disease of younger people can make diagnosis in later life feel especially shameful. Older adults may delay testing or avoid discussing their sexual health because they do not perceive themselves – or are not perceived by others – as being at risk. This can affect testing, disclosure, mental health and continued engagement with care.
Comorbidity
The Lancet Commission supports our findings that over-50s are more likely to receive a delayed HIV diagnosis, and calls for tailored HIV prevention and screening for this age group. It further recognises the need for thoughtful screening and management of age-related comorbidity.
In addition it calls for the integration of HIV services with health services provided to the general public.
A distinctive strength of our work is that we do not study HIV in isolation. Through the long-term research undertaken be the MRC/Wits Agincourt Unit and AWI-Gen, we have spent years examining ageing and health in African populations. Our longitudinal data allow us to consider HIV alongside hypertension, diabetes, obesity and other chronic conditions, and to investigate how these conditions accumulate and interact as people age.
A person may be taking ART with medicines for hypertension and diabetes while also coping with reduced mobility, depression or financial insecurity. Several individually appropriate treatment guidelines can become unmanageable when applied to the same person.
Care must consider physiological rather than chronological age (what’s happening to a person’s body, not just how old they are in years), functional ability (what they are still able to do), polypharmacy (being on multiple medications) and what matters to the individual.
Health systems must also adapt to these new circumstances where more people are living with different chronic (long-term) conditions. An older person should not have to attend separate clinics and make repeated journeys. This is particularly burdensome in rural areas.
HIV, chronic disease and healthy-ageing services need to be brought closer together, with HIV testing available through chronic disease services and HIV care routinely addressing non-communicable diseases and mental health.
Looking ahead
The Lancet HIV Commission provides a timely roadmap for responding to this changing epidemic, but its success will depend on evidence generated where the need is greatest.
The international value of this evidence is clear. Historically, much of what’s known about ageing with HIV has come from wealthier settings, yet the overwhelming majority of older adults with HIV now live – or soon will live – in low- and middle-income countries, particularly in sub-Saharan Africa.
The HIV response must prepare for people growing older with HIV while recognising that older people remain at risk of acquiring it.
Luicer Anne Ingasia Olubayo – Visiting Researcher at Sydney Brenner Institute for Molecular Bioscience, University of the Witwatersrand
Francesc Xavier Gomez-Olive Casas – Research Manager at MRC/Wits Agincourt Research Unit, University of the Witwatersrand
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 Ingasia Olubayo, Theophilous Mathema, F. Xavier Gómez-Olivé et al.
Published in Lancet Health Longevity on 25 March 2025
Summary
Background
Sub-Saharan Africa’s ageing population includes a rising number of adults aged 50 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 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.
See more from MedicalBrief archives:
Older HIV+ adults to overtake younger patients by 2040 – Lancet report
HIV among older South Africans neglected – Wits-Harvard study