People aging with HIV (PAWH) often face complex health challenges that unfold over time and across systems where care is inconsistent, support can be fragmented, and the realities of aging are too often ignored. By highlighting insights from the HealthHIV State of Aging with HIV™ Fourth Annual National Survey, this institute will examine how these experiences are shaped by underdeveloped geriatric expertise, persistent gaps in care coordination, and the lack of alignment between HIV services and aging-related systems.