This review points out unmet medical needs and open research questions of older adults living with HIV. Starting from the definition of aging in HIV, it explores the mosaic of this condition at epidemiological, pathophysiological, and clinical level. Antiretroviral management and diverse models of care are critically discussed.Aging cohorts suggest HIV as a paradigm of chronic inflammation and immune activation with specific aging trajectory patterns in which antiretroviral therapy may play a role. In the absence of randomized clinical trials, observational cohorts show that therapy is driven by duration of HIV infection and burden of non-infectious comorbidities. This review suggests that geriatric approach should be used to recognize the complexity of aging goes beyond the viro-immunological success and management of progressive accumulation of non-communicable diseases. This requires recognition of frailty and geriatric syndromes to stratify patients' diversity by using comprehensive geriatric assessment tools.