Older people with HIV are an essential part of the continuum of HIV care

Advances in antiretroviral therapy (ARV) have offered people with HIV vastly improved, although not normal, life expectancies [1] and have changed the epidemiology of HIV care [2]. Nonetheless, even though this is a worldwide phenomenon [3], with an estimated 6.7 million people 50 years and older living with HIV [4], we do not know how best to care for this population. Older people living with HIV (PLWH) are at higher risk than their uninfected counterparts for multimorbidity [5], cognitive impairment [6], polypharmacy [7], depression [8], loneliness [9], frailty [10] and other medical and social problems. To the already complex intersectionality of stigmas due to their HIV infection and to any of a combination of sexual orientation, gender identity, racism and injection drug use, one must add ageism [11], which can isolate older PLWH from groups that had been more welcoming when they were younger. Those of us who provide care to older PLWH must compete with other HIV constituencies for very limited funding to improve access and provision of care, while at the same time trying to determine best practices to meet the needs of this older, diverse population. Appropriate care of older PLWH is a challenge in both resource-rich and resource-limited settings. In some areas, too much care – too many specialists, too many drugs – may be the primary problem. In other settings, even underserved areas within resource-rich countries, lack of access to care (especially from subspecialties) because of inadequate resources, poor or no insurance, and/or stigma may be the primary concern. All settings require better integration of primary and specialty care; of mental health and medical health; and of medical setting and community. All settings must plan for burgeoning long-term care needs. Even in the absence of an evidence base for how care should be provided to older PLWH, clinical programmes have been initiated to try to address ageing issues. Table 1 provides examples of the basic models of care. One model for geriatric HIV programmes is consultative [16], where HIV providers can refer patients to ageing specialists, usually although not always geriatricians. These services may consist of a single geriatrician or a team of providers; may be embedded or external to the programme; may have specific or general referral criteria; and often include other services or programmes or linkages to community-based organizations. The foundation of the consultation is comprehensive geriatric assessment (CGA), which encompasses medical, social, functional, psychological, and other domains [16]. The advantages of this model are the ageing specialists’ understanding of the older person and the holistic frame of reference that CGA provides. The disadvantages are that (1) these ageing experts may not have effectively adapted tools designed for octoand nonagenarians in the general population to PLWH, who may be several decades younger; and (2) as outsiders, consultants have little control over the implementation of their recommendations. A second model has evolved from long-standing metabolic clinical programmes that have provided care for and often studied PLWH with complex comorbidity and metabolic complications. Their providers have recognized the increasing prevalence of frailty and sarcopenia and are now trying to address them, as well. These programmes have the distinct advantage of having incorporated and internalized these agerelated concerns; treatment protocols are not recommended – they are implemented. The disadvantage of these programmes stems from their origins as metabolic clinics. Without vigilance, they run the risk of focusing too much on multimorbidity (especially if care of individual comorbidities is protocoldriven) at the expense of psychosocial needs. Some programmes have been initiated outside the clinical setting and are focusing on improving older PLWH engagement. One example is mysmartage.org, a smartphone platform that collects passively and actively inputted health information and offers coaching to help people stay healthy [17]. We have also learned of a virtual passport in France to help older PLWH and their providers know what screening and preventive strategies are appropriate for them. In addition to those listed in the table, many clinical programmes for older PLWH are in the planning stages or just starting. Through personal communications, we have learned Siegler EL et al. Journal of the International AIDS Society 2018, 21:e25188 http://onlinelibrary.wiley. com/doi/10.1002/jia2.25188/full | https://doi.org/10.1002/jia2.25188