By Sunkanmi Folorunsho
The aging of the HIV-positive population is a defining feature of the 21st century, necessitating a reassessment of existing healthcare policies and service provisions. As antiretroviral therapy (ART) has extended life expectancy, more than half of all people living with diagnosed HIV in the United States are now aged 50 or older, a proportion expected to grow in the coming decades (HIV.gov, 2024). Despite advancements in biomedical management, older adults with HIV experience disproportionate health burdens, including accelerated aging, multimorbidity, cognitive decline, and mental health challenges. This reality raises an important question: to what extent has public health policy evolved to meet the needs of this aging demographic? While governments have framed HIV/AIDS responses around treatment access and viral suppression, the broader healthcare and social support requirements of older individuals with HIV remain secondary concerns, relegated to fragmented systems and outdated frameworks that fail to integrate HIV and geriatric care effectively (Think Global Health, 2023).
The central issue is that aging with HIV is not merely about living longer but about managing the compounded effects of chronic illness, stigma, and social marginalization. Studies have consistently shown that older adults with HIV develop age-related diseases earlier than their HIV-negative counterparts, often experiencing cardiovascular disease, kidney dysfunction, osteoporosis, and neurocognitive disorders at higher rates and younger ages (Greene et al., 2023). The biological, psychological, and economic dimensions of aging with HIV demand a coordinated policy response that extends beyond traditional HIV treatment models. Yet, current policies remain inadequate, constrained by structural inefficiencies, financial barriers, and a lack of political urgency. While HIV policies have historically prioritized access to life-saving drugs, they have failed to evolve into comprehensive frameworks that address the long-term health and social needs of those who have survived into older age. The absence of a unified, integrated system for aging individuals with HIV exposes the limitations of policy frameworks that continue to focus on viral suppression while neglecting the full spectrum of aging-related challenges (O’Neill Institute, 2024).
Policy Gaps in HIV and Aging
The intersection of HIV and aging reveals structural deficiencies in health policy, particularly in the areas of service integration, healthcare access, financial security, and social support. The failure to recognize HIV as a condition requiring specialized aging-related care has left many older adults navigating a disjointed system that treats their comorbidities in isolation rather than through a holistic framework. The consequences of these gaps are far-reaching, exposing individuals to delayed diagnoses, inadequate mental health care, financial hardship, and social exclusion.
1. The Fragmentation of HIV and Geriatric Care: For much of the HIV epidemic, treatment models were structured around acute, life-threatening infections, prioritizing viral suppression, opportunistic infection prevention, and immune system monitoring. These frameworks, however, fail to address the realities of aging with HIV, where the focus must shift to chronic disease management and long-term health maintenance. The disconnect between HIV specialists, primary care physicians, and geriatricians results in suboptimal management of multimorbidity, particularly in cases involving cardiovascular disease, diabetes, osteoporosis, and cognitive impairments (Ellis et al., 2022). The lack of coordinated care models means that older adults with HIV are often left navigating multiple, unconnected medical systems, each treating individual conditions separately rather than as part of an interconnected aging process.
One pressing issue is polypharmacy, where older individuals with HIV are prescribed multiple medications to manage both HIV and aging-related conditions. Drug interactions between ART and medications for hypertension, diabetes, and mental health conditions can lead to serious adverse effects, yet many providers remain unfamiliar with the complexities of these interactions (HIV Clinical Guidelines, 2023). Despite documented risks, there are no formalized policies requiring geriatric-HIV pharmacological oversight, leaving patients vulnerable to inconsistent treatment plans and increased medication-related complications.
2. Barriers to Healthcare Access and Coverage: While Medicare, Medicaid, and the Ryan White HIV/AIDS Program provide essential healthcare coverage, gaps in eligibility, coverage limitations, and restrictive benefit structures make it difficult for many aging individuals with HIV to receive comprehensive care. Medicare, for instance, does not cover essential services such as long-term case management, mental health support, or home healthcare, leaving older adults with HIV—many of whom have limited financial resources—without the services necessary to manage their complex health needs (KFF, 2024). Unlike other chronic conditions, which benefit from geriatric-specific care frameworks, HIV remains categorized under infectious disease care, preventing HIV-positive older adults from accessing specialized aging-related services.
The issue of long-term care access is equally troubling. Many assisted living and nursing home facilities are not equipped to care for individuals with HIV, and HIV-related stigma persists among healthcare staff in these settings. Research has shown that older adults with HIV often face discrimination in long-term care facilities, leading some to delay or avoid seeking essential support services (O’Neill Institute, 2024). This reluctance is further compounded by financial insecurity, as many older individuals with HIV entered retirement age with fewer financial resources due to job discrimination, lower lifetime earnings, and periods of disability.
3. Mental Health, Social Isolation, and Stigma: The psychological toll of aging with HIV is exacerbated by social isolation, stigma, and untreated mental health conditions. Studies indicate that older adults with HIV experience higher rates of depression and anxiety compared to their HIV-negative peers, yet mental health screenings remain inconsistently integrated into HIV care protocols (HealthHIV, 2023).
For LGBTQ+ older adults, who constitute a substantial proportion of the aging HIV-positive population, these issues are even more pronounced. Many survived the early AIDS epidemic, lost social networks, and now face aging with minimal familial or community support. Some fear seeking care in traditional aging services due to a history of discrimination within healthcare settings, further reinforcing patterns of isolation and untreated mental health concerns.
Addressing Policy Gaps in HIV and Aging
A fundamental step toward improving health outcomes for older adults with HIV is the integration of HIV and geriatric care into a single, cohesive model. Historically, HIV care has remained isolated from broader geriatric services, resulting in fragmented treatment plans that fail to address the complex interactions between aging and HIV-related conditions. Providers specializing in HIV often lack training in geriatric medicine, while primary care physicians and geriatricians may not fully understand the implications of long-term HIV treatment. A policy shift that mandates collaborative care models incorporating HIV specialists, geriatricians, mental health professionals, and social workers would ensure that aging individuals receive comprehensive, multidisciplinary support (Guaraldi & Rockwood, 2017). Additionally, cognitive health screenings should be incorporated into routine HIV care for individuals over the age of 50, as early identification of HIV-associated neurocognitive disorders (HAND) would allow for timely intervention and tailored management strategies (Herrmann et al., 2019).
Equally pressing is the need for expanded healthcare coverage and long-term care access. Despite the existence of Medicare, Medicaid, and the Ryan White HIV/AIDS Program, many older adults with HIV still find themselves navigating coverage gaps that limit their access to essential services such as home healthcare, long-term case management, and specialized geriatric care (KFF, 2024). Medicare policies should be revised to include comprehensive aging-related services for individuals with HIV, ensuring that they are not excluded from necessary support due to outdated classification frameworks. Similarly, Medicaid eligibility requirements should be restructured to provide increased support for low-income aging adults with HIV, particularly those who require assisted living or nursing home care. Furthermore, policymakers must establish incentives for long-term care facilities to accommodate individuals with HIV, addressing both the institutional stigma and the lack of HIV-trained healthcare staff that continue to create barriers for those in need of assisted living (Health Policy Project, 2013).
Additionally, integrating mental health support into HIV treatment protocols is essential, particularly for aging individuals living with HIV. Medicare and Medicaid should expand their coverage to include therapy, psychiatric care, and peer support programs tailored to this population. Notably, nearly half (47%) of Medicare beneficiaries with HIV have a diagnosed mental health condition, a significantly higher proportion than the general Medicare population (29%) (Kaiser Family Foundation, 2023). This disparity underscores the necessity for comprehensive mental health services within HIV care frameworks. The Health Resources and Services Administration (HRSA) emphasizes that mental health support can reduce isolation and loneliness among older adults with HIV, highlighting the importance of integrating such services into standard care (HRSA, 2020). By expanding coverage to encompass these critical services, Medicare and Medicaid can play a pivotal role in enhancing the quality of life and health outcomes for aging individuals living with HIV.
Lastly, community-based initiatives that foster social connection, reduce isolation, and provide mental health education should be actively supported through federal and state funding. Particular attention must be given to LGBTQ+ individuals aging with HIV, many of whom face compounded discrimination, loss of social networks, and reluctance to seek care due to past experiences of stigma within the healthcare system.
References
Ellis, R. J., Letendre, S., Atkinson, J. H., Clifford, D. B., & Grant, I. (2022). Cognitive aging in HIV infection: Emerging issues in research and clinical care. Neurobiology of Aging, 123, 54–64. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9026515/
Greene, M., Justice, A. C., Lampiris, H. W., & Valcour, V. (2023). Management of human immunodeficiency virus infection in advanced age. JAMA, 329(4), 379–390. https://jamanetwork.com/journals/jama/fullarticle/2789051
Guaraldi, G., & Rockwood, K. (2017). Geriatric-HIV medicine is born. Clinical Infectious Diseases, 65(3), 507–509. https://doi.org/10.1093/cid/cix316
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Health Resources and Services Administration (HRSA). (2020). Addressing the health care and social support needs of people aging with HIV. https://ryanwhite.hrsa.gov/sites/default/files/ryanwhite/resources/hrsa-aging-tep-summary.pdf
Health Policy Project. (2013). Achieving a stigma-free health facility and HIV services: A resource for administrators and health professionals. Retrieved from https://www.healthpolicyproject.com/pubs/281_SDAdministratorsGuide.pdf
Herrmann, S., McKinnon, E., Skinner, M., Duracinsky, M., Chaney, R., Locke, V., & Mastaglia, F. (2019). Screening for HIV-associated neurocognitive impairment: Relevance of psychological factors and era of commencement of antiretroviral therapy. The Journal of the Association of Nurses in AIDS Care, 30(1), 42–50. https://doi.org/10.1097/JNC.0000000000000040
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Kaiser Family Foundation (KFF). (2024). Medicare and HIV care coverage. https://www.kff.org/
O’Neill Institute. (2024). HIV and aging: Policy challenges and recommendations. https://oneill.law.georgetown.edu/