The Shifting Age Distribution of People With HIV Using Antiretroviral Therapy in the United States

Keri N. Althoff; Cameron N. Stewart; Elizabeth Humes; Jinbing Zhang; Lucas Gerace; Cynthia M. Boyd; Cherise Wong; Amy C. Justice; Kelly A. Gebo; Jennifer E. Thorne; Anna A. Rubtsova; Michael A. Horberg; Michael J. Silverberg; Sean X. Leng; Peter F. Rebeiro; Richard D. Moore; Kate Buchacz; Parastu Kasaie


AIDS. 2022;36(3):459-471. 

In This Article

Abstract and Introduction


Objective: To project the future age distribution of people with HIV using antiretroviral therapy (ART) in the United States, under expected trends in HIV diagnosis and survival (baseline scenario) and achieving the ending the HIV epidemic (EHE) goals of a 75% reduction in HIV diagnoses from 2020 to 2025 and sustaining levels to 2030 (EHE75% scenario).

Design: An agent-based simulation model with mathematical functions estimated from North American AIDS Cohort Collaboration on Research and Design data and parameters from the US Centers for Disease Control and Prevention's annual HIV surveillance reports.

Methods: The PEARL (ProjEcting Age, MultimoRbidity, and PoLypharmacy in adults with HIV) model simulated individuals in 15 subgroups of sex-and-HIV acquisition risk and race/ethnicity. Simulation outcomes from the baseline scenario are compared with outcomes from the EHE75% scenario.

Results: Under the baseline scenario, PEARL projects a substantial increase in number of ART-users over time, reaching a population of 909 638 [95% uncertainty range (UR): 878 449–946 513] by 2030. The overall median age increased from 50 years in 2020 to 52 years in 2030, with 23% of ART-users age ≥65 years in 2030. Under the EHE75% scenario, the projected number of ART-users was 718 348 [703 044–737 817] (median age = 56 years) in 2030, with a 70% relative reduction in ART-users <30 years and a 4% relative reduction in ART-users age ≥65 years compared to baseline, and persistent heterogeneities in projected numbers by sex-and-HIV acquisition risk group and race/ethnicity.

Conclusions: It is critical to prepare healthcare systems to meet the impending demand of the US population aging with HIV.


Since the introduction of effective antiretroviral therapy (ART) in 1996, life expectancy of people with HIV (PWH) in the US has improved substantially.[1] In 2012, HIV treatment guidelines recommended immediate ART initiation among all people diagnosed with HIV regardless of their CD4+ cell count.[2] Early treatment and improved survival on ART has led to an increasing prevalence of HIV in the United States with >1 million PWH in 2019, among whom 52% were age ≥50 years and 11% were age ≥65 years.[3] Yet, significant disparities in life expectancy of PWH persist, affecting the age distribution of PWH by sex-and-HIV acquisition risk groups and race and ethnicity.[4]

The Ending the HIV Epidemic: A Plan for America (EHE) initiative was announced in early 2019 with the overarching goals of achieving 75% reduction in new HIV diagnoses by 2025 (EHE75%) and at least 90% reduction by 2030.[5] Without a cure, however, the HIV epidemic will persist among populations infected with HIV for decades to come. As such, it is critical to prepare and strengthen HIV care systems to meet the needs of people aging with HIV, including strategies for long-term viral suppression, ensuring uninterrupted access to ART and prevention and care for comorbid conditions. At present, the future age distribution and heath care needs of PWH in the United States among sex-and-HIV acquisition risk groups, and by race and ethnicity within these groups remains uncertain. The objective of this study was to project the age distribution of PWH using ART from 2020 to 2030, and to assess the impact of achieving short-term EHE goals on future age distributions.