About the Researcher

After medical school and a Masters in Infectious Diseases at the University of Milan, Dr Barbara Castelnuovo moved to Uganda for a short placement to acquire more knowledge and skills in tropical and infectious diseases. She then started working at the Infectious Diseases Institute at Makerere University in 2004 as an infectious disease specialist and soon after she began conducting clinical research.

In 2018, Dr Castelnuovo applied for a senior fellowship funded by EDCTP, and focused her proposal on building capacity for research in older people with HIV and geriatric care. Through this funding, she was able to start a cohort study of people with HIV over 60 years while training Master and PhD students. Initially it was difficult to find trainees interested in geriatric medicine, likely because Uganda is a country with a very young population, and older people with HIV were not perceived as a priority group.

Today, Dr Castelnuovo is passionate about advocating for the improvement of clinical care for older people in Africa; she leads a small, but vibrant research team formed by her previous and current trainees including nurses, physicians, pharmacists, and statisticians. Dr Castelnuovo's team have engaged in many international collaborations and students exchange opportunities to train future doctors and researchers.

Older people with HIV in South Saharan Africa: the lessons that we are learning can promote healthy aging for all older people.

By Dr Barbara Castelnuovo

I started my work as a doctor in Uganda at the time of the scale up of antiretroviral treatment (ART). People with HIV had been waiting for years to get access to ART and many presented at late stage of disease with several opportunistic infections. My first research work focused on how to rapidly link people to care, treat those infections, start ART and monitor its efficacy. With time we observed that, after starting ART, people with HIV experienced good health outcomes including long term survival (1).

Today the face of the HIV epidemic in Africa is changing, and while we still encounter challenges in preventing more infections and ensuring that those with HIV present early into care, the number of people with HIV that are becoming older is increasing. Currently the majority of people with HIV over 50 years in the word live in Africa, with an estimated range between 3.7 million to 6.6 million, and by 2040, up to 25% of people living with HIV in Africa could be aged 50 years and above.

Studies from high income countries report an excess of age-related conditions such as non-communicable diseases and geriatric syndromes in older people with HIV compared with those without (2, 3). This is explained by several factors, including HIV infection itself which leads to ongoing levels of inflammation even in presence of successful ART and viral suppression (4, 5), exposure to certain antiretroviral drugs (6) and other life style related factors.

Studies and reports from sub-Saharan Africa are still limited, but currently there is evidence that, similarly to high income countries some conditions may be more common in older people with HIV as compared to those without. For example, kidney impairment due to the double burden of HIV infection and exposure to some drugs like tenofovir is more common in older people with HIV (7).

However, there are reports from different African countries indicating more prompt and effective management of non-communicable diseases like diabetes and hypertension in people with HIV compared to those without (8). Similarly, some aging related conditions like frailty have similar if not lower prevalence in older people with HIV compared to those without (9, 10). Some reports have also demonstrated that older people with HIV receiving care and treatment have higher health-related quality of life than people without HIV (11).

The paradox we are observing demonstrates that linkage to health systems, with periodic encounters with health care workers provides benefits beyond HIV care, including access to other primary health care, peer and other social support, and counselling, may contribute to reversing or at least reducing the negative effect that HIV infection has on aging. We hope that this benefit and gains observed in older people with HIV in Africa will not be undermined but the current funding landscape.

Currently there is not global agreement about priorities for care and research for older people with HIV especially in Sub-Saharan Africa. Challenges to provide comprehensive

geriatric care include costs, trained health personnel and the complexity of geriatric assessment process. Therefore, developing and adapting simplified tools which can be used in these settings for the targeted screening of people at risk of NCDs and geriatric syndromes is paramount.

Acquisition of comprehensive and systematic data from all African counties on non-communicable diseases and aging related condition is also essential for appropriate programming.

Generally older people with HIV in sub-Saharan Africa should be intentionally included in research studies, particularly those evaluating safety of ART regiments. For example dual ART tenofovir sparing regimens, which have been advocated to reduce renal and bone toxicity(12) and would be extremely beneficial in older African people with HIV, have been evaluated in other settings and they cannot be generalizable in this population.

Finally, implementation science research should address how to scale up known intervention to improve outcomes of older people, like multimodal exercise to maintain functionality and prevent falls, dietary advice for appropriate nutrition, treatment of depression and cognitive stimulation (13).

Promotion of healthy aging in people with HIV will not only promote health outcomes of people with HIV but we can potentially learn lessons for the older population in sub-Saharan Africa where health systems are unprepared for geriatric dedicated services (14).

References

1. Castelnuovo B, Kiragga A, Musaazi J, Sempa J, Mubiru F, Wanyama J, et al. Outcomes in a Cohort of Patients Started on Antiretroviral Treatment and Followed up for a Decade in an Urban Clinic in Uganda. PloS one. 2015;10(12):e0142722.

2. Guaraldi G, Malagoli A, Calcagno A, Mussi C, Celesia BM, Carli F, et al. The increasing burden and complexity of multi-morbidity and polypharmacy in geriatric HIV patients: a cross sectional study of people aged 65 - 74 years and more than 75 years. BMC geriatrics. 2018;18(1):99.

3. Schouten J, Wit FW, Stolte IG, Kootstra NA, van der Valk M, Geerlings SE, et al. Cross-sectional comparison of the prevalence of age-associated comorbidities and their risk factors between HIV-infected and uninfected individuals: the AGEhIV cohort study. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2014;59(12):1787-97.

4. Breen EC, Sehl ME, Shih R, Langfelder P, Wang R, Horvath S, et al. Accelerated aging with HIV begins at the time of initial HIV infection. iScience. 2022;25(7):104488.

5. Jespersen NA, Axelsen F, Dollerup J, Nørgaard M, Larsen CS. The burden of non-communicable diseases and mortality in people living with HIV (PLHIV) in the pre-, early- and late-HAART era. HIV medicine. 2021;22(6):478-90.

6. Thet D, Siritientong T. Antiretroviral Therapy-Associated Metabolic Complications: Review of the Recent Studies. HIV/AIDS (Auckland, NZ). 2020;12:507-24.

7. Ssemasaazi AJ, Kalyesubula R, Manabe YC, Mbabazi P, Naikooba S, Ssekindi F, et al. Higher prevalence of kidney function impairment among older people living with HIV in Uganda. BMC nephrology. 2024;25(1):321.

8. Manne-Goehler J, Siedner MJ, Montana L, Harling G, Geldsetzer P, Rohr J, et al. Hypertension and diabetes control along the HIV care cascade in rural South Africa. Journal of the International AIDS Society. 2019;22(3):e25213.

9. Mbabazi P, Chen G, Ritchie CS, Tsai AC, Reynolds Z, Paul R, et al. Prevalence and Correlates of Frailty Among Older People With and Without HIV in Rural Uganda. Journal of acquired immune deficiency syndromes (1999). 2024;97(4):402-8.

10. Manyara AM, Manyanga T, Burton A, Wilson H, Chipanga J, Bandason T, et al. Prevalence, factors and quality of life associated with frailty and pre-frailty in middle-aged and older adults living with HIV in Zimbabwe: A cross-sectional study. HIV medicine. 2025;26(1):153-65.

11. Quach LT, Ritchie CS, Tsai AC, Reynolds Z, Paul R, Seeley J, et al. The benefits of care: treated HIV infection and health-related quality of life among older-aged people in Uganda. Aging & Mental Health. 2023;27(9):1853-9.

12. Bedimo R, Lisa R, and Myers J. Systematic review of renal and bone safety of the antiretroviral regimen efavirenz, emtricitabine, and tenofovir disoproxil fumarate in patients with HIV infection. HIV Clinical Trials. 2016;17(6):246-66.

13. Thiyagarajan JA, Araujo de Carvalho I, Peña-Rosas JP, Chadha S, Mariotti SP, Dua T, et al. Redesigning care for older people to preserve physical and mental capacity: WHO guidelines on community-level interventions in integrated care. PLoS medicine. 2019;16(10):e1002948.

14. Ainembabazi P, Gwokyalya AM, Twinamasiko N, Kihumuro RB, Kintu TM, Bongomin F. Assessment of the readiness of health facilities in urban areas to deliver geriatric-friendly care services: a cross-sectional study in Kampala City, Uganda. BMC geriatrics. 2024;24(1):786.