Integrating HIV and chronic disease services for older patients in low-resource settings

September/October 2025 | Volume 24 Number 5

In 2007, Jepchirchir Kiplagat, PhD, worked as a research assistant in the Academic Model Providing Access to Healthcare (AMPATH) program, a partnership between Moi University and Moi Teaching and Referral Hospital in Kenya and a consortium of North American institutions led by Indiana University. AMPATH aims to foster collaborations among health centers and universities that serve populations with significant unmet needs.

“We were looking at morbidity and mortality of people living with HIV admitted to the hospital. My job was to look through the files and see if these are newly identified people living with HIV or people who have been living with HIV and now being admitted due to other conditions.”

During her day-to-day activities, Kiplagat noticed an elderly woman who remained for more than a month on the ward while being treated for oral thrush, diarrhea, and other conditions. “It took quite some time before she was actually tested for HIV (and found to be living with the virus). I, myself, would never have thought to test her. I wondered, How many cases of HIV in older adults are actually missed? How does their unknown status impact their health?”

Over the years, Kiplagat would recall her observation, that HIV testing disproportionately includes young adults and not older adults, yet it wasn’t until 2021 that she found an opportunity through Fogarty’s Launching Future Leaders in Global Health (LAUNCH) Research Training Program to address some of the unmet needs of older adults living with HIV.

Complex interactions

The number of adults aged 50 or older living with HIV, an estimated 13% of all people living with HIV, continues to grow, explains Kiplagat. Successful antiretroviral therapy (ART) contributes to this rising trend, as do new infections among older people.

HIV, ART, and aging interact in complex ways, says Kiplagat. “ART extends life expectancy, yet long-term use can increase the risk of metabolic complications such as insulin resistance (impaired sensitivity to the hormone that regulates blood sugar), dyslipidemia (atypical levels of fats in the blood) and hypertension (high blood pressure).” Often HIV infections are accompanied by chronic inflammation, which accelerates aging and raises cardiovascular risk. Overall risk of coronary heart disease in people living with HIV, is about twofold higher than in uninfected people.

Yet there are positives: “Older adults living with HIV have about 97% to 98% viral load suppression, so we really need to maintain those rates,” says Kiplagat. While her PhD work revealed that fragmented health care services and systems make it difficult for older adults with HIV to remain in treatment, she hypothesized that holistic care would help them adhere to treatment plans.

Her Fogarty project investigated whether integrating hypertension and diabetes screening within the HIV care platform would be feasible and acceptable to both healthcare providers and patients. Interviews with healthcare providers revealed that structural issues, including a lack of both time and guidelines, diminished but did not completely extinguish their motivation to provide blended services. The patients themselves expressed appreciation of a one-stop care model to replace having to seek out (and pay) multiple providers.

BMC Geriatrics has published Kiplagat’s early findings from her Fogarty project, while a second paper is slated for publication in PLOS Global Public Health. “One of its key findings is that 50% of older people with HIV had hypertension, yet less than half of them had achieved hypertension control,” she says.

Photo courtesy of Jepchirchir Kiplagat A training session for research assistants working with Jepchirir Kiplagat

Policy shifts

Today, Kiplagat’s Fogarty-funded research is shaping discussions within Kenya's Ministry of Health. “I’ve become a person they call—and continue to call— asking about integration of non-communicable disease services into the HIV care platform for older people.” Importantly, a comprehensive geriatric assessment developed in the U.S. and Canada is currently in testing at AMPATH based on her recommendation. “It’s important to assess conditions early so they can be managed instead of participants developing difficult-to-control complications.”

Now a lecturer at Moi University School of Public Health, Kiplagat is working on a National Heart Lung and Blood Institute (NHLBI)-funded project, Community-Based Medication Adherence Support for Older Adults Living with HIV and Hypertension. “Fogarty gave me a platform to generate preliminary data and refine my research questions and establish this collaboration, making it possible for me to compete for NHLBI funding.”

For this pilot study, community health volunteers are tasked with making home visits, measuring blood pressure, conducting motivational interviews, and arranging pills for older adults living with HIV. The project ranges across three sites in Kenya affiliated with AMPATH: a rural facility, a peri-urban facility and an urban facility. “We spent time between 2023 and 2024 refining the intervention through co-design workshops with the patients, the caregivers, the healthcare providers, and the community health volunteers. We are now four months into the one-year pilot of the intervention and, hopefully, by May of next year, we will begin assessing its feasibility and budget impact and then we can move that to scale!”

“Co-design is difficult but in the end it simplifies implementation. You've already taken into account people's feelings, people's perceptions, people's needs, so when you implement, it has better buy-in than when you design it by yourself,” advises Kiplagat.

Reciprocal innovation

Estimates suggest that, by 2030, 70% of people living with HIV in the U.S. will be older than age 50, notes Kiplagat. “While my research is based in Kenya, the issue that I study—aging with HIV—applies to the U.S.” In some areas of America, people struggle with fragmented health services just as many do in Kenya, says Kiplagat: There might be opportunities to utilize U.S. community health volunteers to support patients in their homes as they do in her pilot study.

Reciprocal innovation, where solutions developed in a resource-limited setting like Kenya can inform practices in the U.S., is invaluable, says Kiplagat. “It’s this two-way exchange that makes global health truly global.”

Meanwhile, she often recommends that colleagues and mentees apply to Fogarty’s LAUNCH program. “The fellowship allowed me to step into global health research arena, yet continue to remain deeply rooted in the realities of local health systems.”