South Africa's HIV treatment triumph faces new challenge — the rise of age-related illnesses

Daily Maverick

15-05-2025

The success of South Africa's HIV treatment programme — the largest in the world — has also created a slumbering threat: a considerably larger group of people who need to be treated for age-related illnesses such as diabetes, heart conditions and high blood pressure — also called noncommunicable diseases — on top of having to receive HIV care.
Because antiretroviral drugs (ARVs) keep people healthy and increase their life expectancy, the scale-up of treatment in South Africa — public sector treatment started in 2004 and in 2025 we've got about 6-million people on ARVs — means that most people with HIV and who take ARVs correctly now live just as long as those without the virus.
Bhekisisa's data analysis shows the proportion of older people with HIV doubled over the past decade: people over 50 are now the second biggest HIV-positive group in South Africa today; 15 years ago, they were the smallest group.
If this trend carries on, there could be three times as many HIV-positive people over 50 by 2030 as in 2015.
As people age, their chances of developing health problems like high blood pressure, heart disease and diabetes rise, which means that people with HIV might live long lives, but not necessarily healthy ones.
With nearly two-thirds of all people with HIV living in sub-Saharan Africa, the continent will keep on bearing the brunt of the epidemic — despite massive gains in curbing new infections over the past 15 years — if health systems aren't geared to handle a growing number of people who have both HIV and a chronic illness like heart disease or diabetes.
Experts raised the alarm about this 'inevitable price of success' more than a decade ago. Yet, write the authors of an editorial in a March issue of The Lancet Healthy Longevity, without thorough data on older people with HIV in African countries, putting plans for their healthcare in place will be hard — or may not be done at all.
And with many countries' governments, including South Africa's, scrambling to find the money to replace the thousands of data capturers for HIV programmes previously funded by the US government after the abrupt halt in aid, funds for tracking health conditions of older people with HIV will probably be a low priority.
In the wake of funding cuts, employing health workers to capture and manage health data would be a hard sell, said Kate Rees, a public health specialist with the Anova Health Institute, during a webinar hosted by Bhekisisa and the Southern African HIV Clinicians Society on Thursday — something that, for a public health issue that might be ignored because its fallout isn't immediately visible — could just make the problem so much worse.
What then, does South Africa's picture look like, and could policymakers focus forward to stave off a calamity in the making?
Here's what the numbers show.
Doubled in a decade
The proportion of people with HIV and who are 50 or older is growing — and faster than increases in other age groups.
In 2015, the count in the 50+ age group was just over 700,000, which translates to about 12% of the total HIV-positive population. The age group 40-49 years, though, was about 1.3 million strong, which works out to 22% of the total.
A decade later, the 50-plus total had jumped by 1.15 million to reach 1.85 million, and they now make up roughly 24% of the total number of HIV-positive South Africans.
Although the 40-49 group's total also grew by 1.15 million, proportionally they now make up 32% of everyone.
In other words, the proportion of older people with HIV doubled in a decade, but the proportion of people 10 years younger grew only 1.5 times bigger — a result, experts say, of people with HIV living longer, new infections still happening in older people and fewer new cases in the younger group. If this trend continues, there could be three times as many HIV-positive people over 50 by 2030 as in 2015.
Speeding up, changing ranks
People over 50 are the second biggest HIV-positive group in South Africa today. Fifteen years ago, they were the smallest group.
Around 2012, the 50-plussers moved up one rank, surpassing growth in the under-20s group. But the number of HIV-positive people between 35 and 49 grew rapidly — so much so that by around 2012 they overtook the group aged 20-34 and assumed top rank.
In the following years, the 50+ group increased too: people moved out of their late forties and new infections in that age group continued. By 2026 — about 10 years since their previous rank jump — people over 50 will already have been the second biggest group of the HIV-positive population for some time.
The 35-49 years group will keep on growing in the next five years, modelled data shows, albeit more slowly than before. Because people are living longer, the older group will grow too as people move into their fifties, and because it's been expanding for some time already, the group will edge closer and closer to top rank over the coming years.
Living long, but not necessarily healthy
This is where the warning lies.
Data from 2020 shows that, when Covid-19 is ignored, one in seven deaths in people between 45 and 64 years old were due to health problems like heart attacks, stroke and high blood pressure that year. In comparison, only one in 20 deaths in that age group were linked directly to HIV.
Above age 65, a quarter of deaths were from these conditions. So few were linked to HIV in this age group that, proportionally, it was hardly a noticeable concern.
So, as the peak of the HIV-infected population shifts into an older age band, more and more people will probably have to be treated for noncommunicable diseases like heart conditions, diabetes, obesity and high blood pressure — on top of receiving HIV care.
In fact, in a large study in Mpumalanga, in which most people were in their late 40s to early 70s, about half had at least two age-related illnesses.
For example, in this sample of just over 5,000 people, six in 10 had high blood pressure, with it being more likely the older someone was. About 10% of women had bad chest pain, called angina (which happens when the heart doesn't get enough oxygen-rich blood), and up to 11% of people had high cholesterol.
High blood pressure combined with high cholesterol is bad for your heart. It can damage your arteries, and especially those that supply oxygen-rich blood to the heart. In turn, this ups the chances for fatty plaques building up along the walls of the blood vessels. This narrows and stiffens the arteries, meaning blood pressure builds up even more and the chance of a blood vessel rupturing increases.
High blood pressure can lead to angina or a heart attack because the heart muscle gets too little oxygen, and also cause a suite of other health problems called metabolic syndrome, which includes conditions like diabetes, stroke and heart disease.
Age-related health problems like heart disease, diabetes and being overweight are often linked to inflammation. This is a natural response of the immune system when tissues are damaged, like when we get older.
However, inflammation is even more common with HIV-infection — because of the body's immune response, damage caused by the virus itself and also the effects of ARV treatment — and studies have shown that people with HIV who are older than 50 have double the chance of having conditions like diabetes or high blood pressure than what is seen in younger HIV-positive people.
'In future, every clinic nurse will have to be Nimart trained,' said Ndiviwe Mphothulo, the president of the Southern African HIV Clinicians Society at last week's webinar.
Nimart nurses — short for Nurse-Initiated Management of Antiretroviral Treatment — are specially trained in how to prescribe ARVs and how to manage long-term patients.
But, experts say, the flip side is also true if South Africa is to deal with the ageing HIV epidemic: every Nimart nurse will have to be equipped to deal with noncommunicable diseases in this population too. DM