Aging with HIV in Botswana: Time to Update Our Treatment Guidelines

A New Face of Botswana’s HIV Epidemic

As an HIV activist, I have witnessed a profound shift in our epidemic’s demographics. Two decades ago, the focus was on keeping people alive. Today, thanks to widespread antiretroviral therapy (ART), many of those same people are alive into their 50s, 60s, and beyond. In fact, Botswana’s HIV population is graying rapidly. By some estimates, over 50% of people living with HIV in Botswana are now over 40 years old, making older adults the new face of our country’s HIV community. This is a testament to our success in expanding treatment, but it also presents urgent new challenges.

While ART has extended life expectancy, additional years of life are not necessarily spent in good health. Many older PLHIV are surviving, but not thriving. They struggle with chronic pain, fatigue, heart disease, or depression. Such stories underscore a hard truth: we have won on longevity, but we are lagging on quality of life. Medical complications, multimorbidities, and even social issues such as isolation are eroding the health and dignity of too many older people living with HIV. It is time for Botswana to recognize this second chapter of the HIV epidemic and respond with the same commitment we brought to the first.

Life After ART: Longer Lives, New Health Challenges

There is no question that Botswana’s aggressive ART program saved lives. HIV has been transformed from a death sentence into a manageable chronic condition. Now we have a generation of survivors aging with the virus. Our health system and national HIV guidelines were built to handle acute infection and to get ARVs to as many people as possible, not to address the unique needs of someone who has been living with HIV for 20 or 30 years.

Older PLHIV commonly have multiple co-existing conditions, such as diabetes, hypertension, heart disease, liver or kidney problems, and cognitive impairment. Decades of HIV infection and long-term ART side effects can accelerate age-related illnesses. Research shows that HIV-positive people can exhibit geriatric conditions like frailty at younger ages than their HIV-negative peers. A 50-year-old living with HIV might have the physical resilience of someone 15 years older.

Botswana’s current HIV care framework does not fully address these realities. Our national treatment guidelines focus on suppressing the virus and preventing opportunistic infections. But they say little about geriatric care or how to manage an HIV patient with multiple chronic illnesses. Front-line doctors and nurses have not been systematically trained in the geriatrics of HIV. As a result, older patients often get fragmented care. We need a more holistic approach if we want our HIV survivors to live not just longer, but better.

Frailty and Age-Related Conditions: The Silent Shift

One area of growing concern is frailty, a syndrome of decreased reserve and resilience leading to a higher risk of falls, disability, and death. Frailty is something we expect in the very elderly, but it is appearing in PLHIV in their 50s and 60s. Recent studies have found that nearly one in five older people living with HIV show signs of frailty, even in their early 60s.

Biological factors related to long-term HIV infection and ART are key contributors. Additionally, social factors play a role. Many older PLHIV lack regular social interaction and support, which impacts overall well-being. Botswana must treat this shift as a call to action. We cannot focus only on the virus and ignore the whole person. Interventions that support health and stability should be a routine part of HIV care.

Botswana’s HIV Guidelines: The Gap for Older Adults

Despite the clear need, Botswana’s national HIV treatment guidelines do not yet explicitly address aging and frailty as specialized areas of care. The latest guidelines provide protocols on ART initiation and co-infection management, but there is no guidance on geriatric HIV care, frailty assessments, or cognitive decline.

Importantly, Botswana should also include routine bone density screening starting at age 50 as part of HIV care. PLHIV are at increased risk for osteoporosis and fractures due to the effects of HIV and certain ART regimens. Monitoring bone health proactively can prevent serious complications.

Moreover, we must begin to implement one-stop clinics at ARV facilities to manage multimorbidities. These integrated clinics would offer screening and treatment for non-communicable diseases, mental health, and aging-related issues in a single visit. This approach reduces the burden on patients and improves continuity of care.

Incorporating aging into the guidelines would send a powerful signal that the Ministry of Health prioritizes the well-being of older PLHIV. It would encourage the development of HIV-geriatric services, specialized clinic days for older patients, and multidisciplinary teams including geriatricians and specialists.

Training Health Workers in Geriatric HIV Care

Updating guidelines is not enough. We must also train our health workforce to meet the needs of older PLHIV. Most doctors, nurses, and community health workers learned about HIV in the context of younger patients. They need updated training on managing older patients with multiple conditions, recognizing frailty, and screening for cognitive issues.

Workshops on polypharmacy, mental health, and geriatric assessments should be integrated into HIV training curricula. Sensitization is key to eliminating ageist attitudes in care delivery. Additionally, peer supporters and community health workers should be trained to conduct outreach to isolated older clients.

Mental Health and Social Support as Core Care Components

Mental health and psychosocial support are essential components of healthy aging with HIV. Older adults are more likely to experience depression and anxiety, often related to past trauma or current health burdens. Mental health screening should be a routine part of care, with clear referral pathways for support.

Community-based interventions, such as support circles for older PLHIV, can promote connection and improve emotional well-being. Churches and civil society organisations also have a role to play in reaching older clients. Regular follow-up, even through phone check-ins, can reduce isolation and ensure ongoing engagement in care.

Involving Older PLHIV in Planning and Research

Older PLHIV must be involved in designing the services that affect them. Their experiences offer critical insight into what works and what does not. Including them in policy development, programme planning, and clinical research ensures services are more responsive and effective.

Older adults should also be part of research studies that examine aging and HIV in Botswana. Understanding local patterns of frailty, bone loss, cognitive decline, and quality of life will allow us to tailor interventions more accurately. Patient advisory boards made up of older PLHIV can help interpret and disseminate findings back to the community.

Conclusion: Embracing Aging in Botswana’s HIV Response

Botswana stands at a turning point. We have successfully extended the lives of tens of thousands of us PLHIV through ART. Now we must ensure that those years are healthy, dignified, and well-supported. Updating our national HIV guidelines to include aging and frailty, incorporating bone health screening, and establishing one-stop multimorbidity clinics at ARV facilities is the way forward.