Aging with HIV: The Epidemic Grew Up

The demographics of HIV in the United States have shifted dramatically. What was once seen as a disease of young adults is now increasingly a condition managed by people in their 50s, 60s, and beyond.^[1] This isn't a failure — it's a testament to how well ART works. But it means the healthcare system needs to evolve alongside the population it serves.

Only 19% of people 65 and older had ever been tested for HIV as of 2022, and just 71% of people 65+ living with HIV received care in 2023 — the lowest of any age group.^[6] When older adults are diagnosed, they're more likely to already have late-stage infection. Late diagnosis means more immune damage, a harder recovery, and a steeper road ahead — which is one reason many advocates argue current CDC screening guidance (routine testing ages 13–64) should be extended to older adults.^[7]

Even with viral suppression, HIV appears to accelerate certain aspects of the aging process. The mechanisms are complex and still being studied, but several factors are now well established.

Chronic immune activation and inflammation. Even when the virus is fully suppressed, people living with HIV carry higher levels of systemic inflammation and immune activation than their HIV-negative peers. This persistent low-grade inflammation — sometimes called "inflammaging" — drives tissue damage across multiple organ systems over time and helps explain the elevated cardiovascular, bone, and cognitive risks that follow.^[8]

Epigenetic aging. Studies using DNA methylation clocks consistently show that people with HIV have biological ages that run ahead of their chronological ages. Research suggests the gap is roughly 5 years — meaning a 50-year-old living with HIV may have the biological age profile of someone in their mid-50s without HIV.^[9]

Immune exhaustion. Years of managing HIV — even fully suppressed HIV — takes a cumulative toll on the immune system. T-cell populations show signs of premature aging, with reduced ability to respond to new infections, cancers, and vaccines. This is called immunosenescence, and it happens earlier in people with HIV than in the general population.

People aging with HIV face a higher burden of age-related comorbidities — and tend to develop them earlier. Modeling studies project that by 2030 most people with HIV on ART will be living with at least one non-HIV condition, and a large share with two or more.^[10] Here are the major ones to understand.

People with HIV have roughly 1.5 to 2 times the cardiovascular risk of the general population.^[11] This is driven by chronic inflammation, certain ART medications (particularly older protease inhibitors), higher rates of smoking, and metabolic changes. Blood pressure monitoring, lipid panels, and cardiovascular risk assessment should be part of every annual visit. In 2024 the U.S. Department of Health and Human Services began recommending statin therapy for primary CVD prevention in people with HIV aged 40–75, based on results from the REPRIEVE trial.^[12] See our HIV & Heart Health Deep Dive for a full guide.

Insulin resistance and type 2 diabetes develop more often in people aging with HIV. Certain ART regimens can contribute to metabolic changes, and chronic inflammation itself drives insulin resistance. Monitoring fasting glucose and hemoglobin A1c should be routine. Weight management and dietary attention matter more for PLHIV than for the general population because of these compounding risk factors.

HIV itself can cause kidney damage, and some antiretroviral medications — particularly tenofovir disoproxil fumarate (TDF) — carry kidney-related side effects. Regular monitoring of kidney function (eGFR and urine protein) is essential, especially for people on TDF-based regimens or with other risk factors like high blood pressure and diabetes. If you're on TDF and aging, ask your provider whether tenofovir alafenamide (TAF) might be a better fit for your bones and kidneys.

While AIDS-defining cancers (Kaposi sarcoma, certain lymphomas) have declined dramatically with ART, non-AIDS cancers — particularly lung, liver, and anal cancers — occur at higher rates in people with HIV.^[13] Age-appropriate cancer screening is critical: colonoscopy, lung cancer screening for those with a smoking history, liver surveillance for those co-infected with hepatitis B or C, and anal Pap smears for those at elevated risk.

Cognitive health is one of the most important — and most anxiety-producing — topics in HIV and aging. A 2021 meta-analysis of 21 studies found that older people living with HIV were about 2.4 times more likely to show cognitive impairment than HIV-negative peers of the same age.^[14] That elevated risk persists even with effective ART and full viral suppression.

HIV-associated neurocognitive disorder (HAND) is a spectrum that ranges from asymptomatic neurocognitive impairment (detectable only on formal testing) to significant impairment that affects daily functioning. The severe HIV dementia common in the pre-ART era is now rare — dropping from about 15% to under 5% among people on suppressive ART — but milder forms of HAND remain common.^[15]

Brain imaging studies show that people with HIV — even those who are virally suppressed — can have lower gray matter volume and white matter changes compared to matched controls. Effective ART can help improve cognition, and maintaining viral suppression remains the single most important thing you can do for your brain health.

Bone density loss is more common and starts earlier in people with HIV. Multiple factors contribute: HIV-related chronic inflammation, certain ART medications (particularly TDF), lower vitamin D levels, lower body weight, smoking, and the effects of aging itself. Meta-analyses find that osteopenia and osteoporosis occur at roughly 2.4 to 3.4 times the rate of matched HIV-negative adults, depending on the skeletal site.^[16]

The result is higher rates of osteopenia and osteoporosis, and a meaningfully increased fracture risk — with fragility fractures occurring about 10 years earlier in PLHIV than in the general population.^[17] Hip fractures in particular carry serious consequences for older adults: long recovery times, loss of independence, and higher mortality risk.

As comorbidities accumulate, so do medications. Roughly 4 in 10 people living with HIV in U.S. cohorts report polypharmacy — commonly defined as taking 5 or more medications concurrently — and the share climbs steeply with age and with each additional comorbidity.^[5] This creates a cascade of clinical concerns: drug-drug interactions, side effects that compound each other, adherence burden, and the risk of one medication undermining another.

ART medications interact with a wide range of other drugs — statins, blood pressure medications, antidepressants, acid-reflux medications, blood thinners, and more. The liver enzymes that metabolize ART are often the same ones processing these other medications, and that competition can raise or lower drug levels unpredictably. Integrase inhibitor-based regimens (dolutegravir, bictegravir) tend to have fewer such interactions than older boosted protease-inhibitor regimens.

Frailty describes a loss of physiologic reserve — reduced strength, endurance, and resilience — that goes beyond normal aging. It predicts falls, hospitalizations, disability, and death. People with HIV develop frailty at higher rates and at younger ages than their HIV-negative peers.^[18]

Frailty isn't inevitable. It can be slowed, stabilized, and in some cases reversed with the right interventions. The key is early identification — by the time frailty is obvious, intervention is harder.

Depression and anxiety are more common among older people living with HIV than in either the general aging population or younger PLHIV. The reasons are layered: grief from the epidemic years, survivor's guilt, the cumulative weight of stigma, physical health challenges, and the particular loneliness of aging with a condition many people still don't understand.^[19]

Social isolation is a compounding factor. Many long-term survivors lost entire social networks to AIDS. Others face isolation because they haven't disclosed their status and carry that secret in silence. Isolation combined with depression is particularly dangerous — it impairs medication adherence, reduces engagement with care, and independently increases mortality risk.

Suicide risk remains elevated for people with HIV compared to the general population, and in some large ART-era cohorts suicide has ranked among the leading causes of death among virally suppressed people on treatment.^[20] Depression screening should be a routine part of every HIV care visit — annually at minimum.

The goal isn't to be afraid of aging — it's to be informed and proactive. Here's what a comprehensive care approach looks like for someone aging with HIV.

Many of the screenings above won't happen unless you ask for them. HIV providers are excellent at managing your virus — but aging-related care often falls through the gaps, especially if you don't have a primary care provider in addition to your HIV specialist. Here are the conversations worth initiating:

Advance care planning. This is a topic that gets overlooked now that people with HIV are living longer. In the early epidemic, these conversations were routine. Now they're not — but they should be. Who makes medical decisions for you if you can't? Do you have a healthcare power of attorney and advance directive? These documents matter for everyone, but especially for people navigating complex chronic conditions.

Finding providers who understand both HIV and geriatric health — or who are willing to learn — makes a real difference. In Florida, Ryan White clinics are a strong entry point, and academic medical centers with HIV programs can coordinate the specialists (cardiology, endocrinology, geriatrics, psychiatry) that aging-related care often requires.^[21]