Physical, mental and psychosocial factors associated with HIV infection have shaped the lives of people affected. Episodic illness and treatment, anxiety and depression and threats to psychological wellbeing presented by HIV-related stigma have resulted in diminished health-related quality of life.  However, improved treatment, lifestyle and psychosocial interventions can mitigate detrimental impacts of HIV infection and increase the possibility for improved coping, optimism and social support. ^{[110, 111]} Inherent resilience to stressful circumstances can also buffer negative HIV-related psychosocial pressure.

Subclinical mood and anxiety disorders are common in people with HIV infection as is susceptibility to HAND, major depression, dysthymia, generalised anxiety disorder and panic attacks. As life expectancy increases, the impact of ageing effects on the brain and psychosocial changes associated with ageing per se are likely to present further challenges. Although rates of reported depression vary between studies, mood disorders are common in men and women, although men appear to have fewer positive relationships, which may affect their capacity to maintain and develop supportive networks.

Episodic illness and treatment-related side effects of ART compromised the employment opportunities and finances for a generation of people with HIV infection. Neurocognitive impairment may necessitate early retirement and limit employment. Lack of employment and meaningful work can negatively affect social engagement and self-worth leading to reduced psychological health. Financial insecurity can increase stress, anxiety and depression and lead to reduced opportunity to engage in health-seeking behaviours.

A common concern for people with HIV infection is uncertainty about the future and ageing in the context of HIV infection. Will they receive quality aged care? What will they be able to afford? Will they be more vulnerable to stigma and discrimination that they may have experienced in the past, by virtue of frailty? Will they need to negotiate disclosure in a potentially unsupportive setting?

Supportive social ties have been shown to enhance physical functioning and mental health in older adults and stressful social ties are recognised as detrimental. ^[112] Social support networks are dynamic and shaped by need and circumstance over the life course. ^[113] These networks are recognised as an important adjunct of successful HIV care, particularly supporting medication adherence; psychological wellbeing and mental health; positive states of mind; coping with the stress of disease and quality of life. Assessing risk of those characteristics that may increase vulnerability to social isolation is an important aspect of HIV management. Some studies have found that older adults have lower levels of social functioning, and report that emotional support is inadequate to their needs. In addition, older adults who find barriers to accessing services have reported more depressive symptoms.

Sexual orientation influences relationships with families and many gay and lesbian adults have formed families of choice and may have similar social network capacity as individuals without infection. This may not be true across cultures and highlight the cultural nuances of stigma concerns.

Key recommendations

1. Assess risk of social isolation (age, gender, sexual orientation, ethnicity, poverty, unemployment, family and friendship ties)
2. Strengthen social assistance packages incrementally and appropriately
3. Screen regularly for depression and anxiety
4. Consider quality of life issues that might impact on psychosocial functioning e.g. financial concerns
5. Identify triggers influencing psychosocial functioning e.g. significant life events: loss of relationship, death in the family, job loss or change.
6. Help people with HIV infection manage HIV disclosure and understand their rights (aged-care accommodation)
7. Target modifiable factors to increase opportunities for social interaction
8. Encourage people to find meaningful activity if deemed of benefit e.g. volunteering, peer navigators.