Ageing with HIV and NCDs in Zimbabwe

Zimbabwe’s Health Landscape

Zimbabwe, a nation of approximately 16 million people, has made significant strides in the global fight against HIV. With over 1.3 million Zimbabweans living with HIV, the country has achieved the ambitious UNAIDS 95-95-95 targets (95% of people with HIV know their status, 95% of people who know their status are receiving HIV treatment, and 95% of people on treatment are virally suppressed). As of the latest government data, more than 1.2 million individuals are on antiretroviral therapy (ART), with around 97% achieving viral suppression, significantly reducing mortality and improving health outcomes.

However, this encouraging progress brings new challenges, particularly as Zimbabwe’s population ages. Research indicates that HIV can accelerate biological ageing due to both the virus increasing the risks for cardiovascular disease, diabetes, and cognitive decline and the long-term effects of ART which may contribute to conditions such as metabolic syndrome and lipid abnormalities commonly associated with ageing (Breen et al. 2022; Akusjärvi & Neogi, 2023). For elderly people living with HIV, having HIV alongside other chronic illnesses (HIV multimorbidity) presents an even greater risk, as it is associated with a higher likelihood of severe health complications and mortality compared to those with multiple conditions but without HIV (Goldstein et al., 2024).

The rural-urban divide significantly impacts the experiences of elderly Zimbabweans living with HIV and non-communicable diseases (NCDs). Urban areas, benefiting from better healthcare infrastructure and resources, generally provide a higher level of care for chronic conditions. In contrast, rural healthcare facilities often struggle with limited resources and staffing, which can affect the management of chronic conditions among the ageing population. Rural regions typically face higher levels of poverty, exacerbating these disparities.

In this article, we explore how rural and urban settings impact health outcomes and quality of life for people over 50 living with HIV. We advocate for a shift beyond HIV care toward integrated, person-centred management to support healthy ageing across Zimbabwe.

Research indicates that HIV can accelerate biological ageing due to both the virus increasing the risks for cardiovascular disease, diabetes, and cognitive decline and the long-term effects of ART which may contribute to conditions such as metabolic syndrome and lipid abnormalities commonly associated with ageing.

In this article, we explore how rural and urban settings impact health outcomes and quality of life for people over 50 living with HIV. We advocate for a shift beyond HIV care toward integrated, person-centred management to support healthy ageing across Zimbabwe.

Urban insights: Pioneering integrated care

Newlands clinic (NC) in Harare, Zimbabwe, has been a lifeline for nearly 8,000 people living with HIV (PLHIV) since 2004, providing essential treatment and care at no cost through a public-private partnership between the Swiss-based Ruedi Luethy Foundation and Zimbabwe’s Ministry of Health and Childcare (MoHCC). Over time, the clinic has seen an increasing number of older patients as advancements in HIV care enable PLHIV to age into later stages of life. Today, 37% (2,951/7,896) of NC’s patients are over the age of 50, a demographic shift that presents both a triumph in HIV treatment and new challenges for Zimbabwe’s healthcare system.

An analysis of NC data reveals that 32% (957/2,951) of patients over 50 have hypertension and 15% (434/2,951) have chronic kidney disease (CKD), and 7% (216/2,951) have diabetes mellitus. Despite these challenges, the clinic has achieved an impressive 96% viral suppression rate among patients aged over 50 years.

In 2022, NC introduced an integrated HIV-geriatric clinic, designed to address the full spectrum of health issues facing elderly PLHIV. Guided by WHO recommendations, the clinic takes a holistic approach (assessing cardiovascular health, the metabolic system, mental well-being, nutrition, cognition, visual acuity and physical functioning). A pilot assessment of 91 patients aged over 65 years found widespread frailty (60% (51/91) required physiotherapy), high cardiovascular risk, (44% (40/91) had an elevated 10-year risk of a heart event and were subsequently offered statin therapy) and significant mental health concerns (8% depression; 20% anxiety). Additionally, 51% were deficient in vitamin B12, a nutrient crucial to neurological health. These findings highlight the importance of proactively addressing broader health issues of older PLHIV.

In 2022, NC introduced an integrated HIV-geriatric clinic, designed to address the full spectrum of health issues facing elderly PLHIV. Guided by WHO recommendations, the clinic takes a holistic approach (assessing cardiovascular health, the metabolic system, mental well-being, nutrition, cognition, visual acuity and physical functioning).

Rural realities: Bridging the gap in healthcare

In rural Zimbabwe, ageing with HIV brings a distinct set of challenges shaped by limited healthcare infrastructure and insufficient resources. Patients often face long, costly and unreliable journeys to reach clinics, making routine check-ups for chronic conditions difficult. The lack of home monitoring equipment, such as blood pressure cuffs or glucometers, means many patients cannot effectively track their health, further delaying interventions and contributing to preventable complications. Village health workers, who are crucial for community-level health services, often lack the necessary tools and training needed to support patients with NCDs, further exacerbating existing gaps in care.

SolidarMed, a Swiss NGO, works with Zimbabwe’s MoHCC in rural Masvingo Province to address these challenges, focussing on strengthening healthcare systems through training healthcare workers (HCW), equipping facilities and integrating NCD screening into HIV programmes. While data on NCDs within SolidarMed’s HIV cohort of 18,441 patients remains limited, anecdotal evidence suggests a growing demand for NCD care as more patients experience age-related health issues alongside HIV.

The scale of the challenge is further illuminated by data from SolidarMed’s separate NCD cohort of 4,500 patients with diabetes and hypertension across 21 supported health facilities from 3 districts. Between January and October 2024, 63% (950/1,500) of hypertensive patients achieved controlled blood pressure (<140/90 mmHg), while 57% (1,020/1,080) of diabetic patients had controlled HbA1c levels (<8%). While these demonstrate progress, they contrast sharply with the nearly 97% viral suppression achieved in HIV care and may not reflect the broader situation outside SolidarMed-supported facilities. For instance, the national health information system records only 9,000 patients with hypertension and diabetes across all 228 health facilities in Masvingo Province’s seven districts (population >1.5 million). This suggests an underestimate, although the expected prevalence is not known as the last STEPS survey, conducted in 2005, covered only three out of the ten Provinces in Zimbabwe.

Despite NCDs accounting for 42% of the country’s disease burden, less than 10% of government health funding is allocated to their management.

Among SolidarMed's NCD patients, 63% (2,869/4,500) are over 50, and 36% (1,617/4,500) are over 65, underscoring the disproportionate impact of NCDs on ageing populations. Managing NCDs requires skilled healthcare workers, uninterrupted medication supplies, regular monitoring, and significant lifestyle changes—all areas where Zimbabwe's health system remains underprepared. Despite NCDs accounting for 42% of the country’s disease burden, less than 10% of government health funding is allocated to their management (Zimbabwe MoHCC, Investment Case for the NHS). This results in a shortage of essential medications and diagnostic equipment for NCD management, limiting facility's ability to provide consistent care and underscoring the urgent need for equitable investment to address aging-related multimorbidity in both urban and rural settings.

Discussion

Zimbabwe’s success in achieving 97% viral suppression among PLHIV demonstrates the effectiveness of a well-funded, disease-specific health response that reached urban and rural populations. However, this progress has highlighted underlying systemic gaps that are being brought to the forefront under the increasing prevalence of NCDs among ageing populations. As seen in SolidarMed’s rural NCD cohort, control rates for hypertension and diabetes still lag significantly behind those for HIV, underscoring the need to go beyond disease-specific approaches and adopt integrated, person-centred care models.

Disease-specific funding, while instrumental in addressing HIV, comes with limitations. Over prioritisation of one condition risks neglecting others, leading to fragmented care. HCW often receive specialised training in the prioritised disease, leaving them less equipped to handle multi-morbidities common among ageing populations.

Disease-specific funding, while instrumental in addressing HIV, comes with limitations. Over prioritisation of one condition risks neglecting others, leading to fragmented care. HCW often receive specialised training in the prioritised disease, leaving them less equipped to handle multi-morbidities common among ageing populations.

A key lesson from Zimbabwe’s HIV response is the importance of investing in HCW capacity, tools, and protocols. HCWs in Zimbabwe are better equipped to manage HIV than NCDs due to decades of investment in HIV-specific training, free medication, and monitoring tools. This has led to streamlined HIV care delivery and motivated HCWs by enabling them to see tangible improvements in their patients’ health. In contrast, NCD care suffers from a lack of national strategy, limited availability of consumables, and minimal training in geriatric and multimorbidity management. Addressing these gaps requires a similar level of commitment to that seen in HIV care.

Integrating NCD screening and management into existing HIV care structures presents a unique opportunity. PLHIV already engage regularly with the health system, making it easier to implement preventative measures, such as cardiovascular risk assessments or diabetes screening, during routine visits. However, prevention, screening and care must extend beyond the HIV population to the general community. Factors such as unplanned urbanisation, poor dietary habits, physical inactivity and substance use (particularly tobacco and harmful alcohol consumption) put all populations at risk for NCDs. Inclusive strategies are essential to addressing this broader health challenge.

References

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