The World Health Organization designated 2021–2030 as the Decade of Healthy Ageing. Population aging and the demand for healthy aging pose significant challenges to Brazil’s Unified Health System (SUS), particularly for people living with HIV/AIDS (PLHIV), who experience accelerated aging with higher prevalence of chronic diseases and geriatric syndromes, requiring needs-focused care. This project aimed to map key clinical and psychosocial problems among PLHIV aged ≥ 50 years in follow-up at the institution and to develop a program to implement an integrated, multidisciplinary care pathway.

A multidisciplinary group was formed to discuss, plan, and structure the proposal. Technical visits were conducted to health services and non-governmental organizations. PLHIV aged ≥ 50 years in outpatient follow-up were mapped. The Multidimensional Assessment of the Older Person (AMPI-AB) was discussed and adapted with HIV-related variables (not counted toward the final score). A pilot project with PLHIV aged ≥ 75 years assessed the applicability of AMPI-AB. Biweekly meetings facilitated discussion and intersectoral resource exchange.

Of 7,700 PLHIV in care, 3,570 (46%) were aged ≥ 50 years. Eighty-seven PLHIV aged ≥ 75 years were included; five were excluded due to death, yielding a final sample of 82. Of these, 12 (15%) were classified as frail and 49 (60%) as prefrail. Forty-one (50%) reported living alone; 80 (98%) had polypharmacy excluding ART; and 31 (39%) had difficulty walking 400 meters. The most prevalent comorbidities were hypertension (52%), diabetes mellitus (26%), vascular diseases (26%), and chronic pain (24%).

The aging PLHIV population imposes significant challenges on specialized services and calls for enhanced care strategies. A multidisciplinary, intersectoral approach is essential for early identification of geriatric syndromes, including frailty, and for promoting longevity with quality of life. Implementing comprehensive care aligns with the complex clinical and psychosocial needs of this population.