Integrating perinatal mental health screening into primary maternal healthcare services in Vietnam - a realist evaluation.

The rapid development of antiretroviral therapy (ART) and the expansion of treatment access have profoundly transformed the trajectory of HIV infection, converting what was once a terminal diagnosis into a manageable chronic condition [, ]. As a consequence, an increasing number of people living with HIV are surviving into older age, and the intersection of HIV management with age-related physiological decline presents unprecedented challenges for residential environment planning [, ]. In China, this demographic shift is particularly pronounced: the proportion of newly reported HIV/AIDS cases among adults aged 60 years and older has risen sharply, from approximately 7.4% in 2010 to nearly 25% by 2023, according to surveillance data from the Chinese Center for Disease Control and Prevention [, ]. This epidemiological trend means that a growing cohort of older Chinese adults must simultaneously contend with the clinical demands of lifelong ART adherence, the physiological consequences of immunosenescence, and the pervasive social stigma attached to HIV status [, ]. Understanding the residential context of older adults living with HIV in China is essential for framing the environmental dimensions addressed in this study. The majority of Chinese older adults continue to reside in family-based settings, either co-habiting with adult children or living independently in long-established residential communities; institutional care remains a minority arrangement, accommodating fewer than 4% of adults aged 65 and older []. For those living with HIV, this predominantly home-based arrangement creates acute privacy tensions: national surveys indicate that a substantial proportion of older adults with HIV have not disclosed their serostatus to family members, and involuntary disclosure through visible medication routines, identifiable clinic visits, or neighbor awareness can trigger familial conflict, social rejection, and intensified psychological distress [, ]. These privacy concerns are compounded by a dual stigma—the intersection of ageism and HIV-related discrimination—which, as [] demonstrated, compounds social exclusion and shapes environmental needs in ways distinct from those of younger HIV-positive populations or the general older population. Consequently, the residential environment for this group must simultaneously address conventional aging-related accessibility demands and HIV-specific requirements for confidentiality, treatment access, and psychosocial support. The living environment constitutes a critical determinant of health outcomes and quality of life among older adults, as articulated by the ecological theory of aging proposed by [] and further supported by research on neighborhood-level determinants of functional limitations in aging populations []. Central to this theory is the concept of —the aggregate of physical, interpersonal, and social demands that a setting places on its occupants—which interacts with personal competence to determine adaptive behavior and psychological wellbeing. When individual competence declines due to aging or chronic illness, even moderate environmental press can exceed coping thresholds, resulting in maladaptive outcomes. Complementing this individual-environment lens, Bronfenbrenner’s [] social-ecological model provides a multilevel framework for understanding how built environments, social networks, and institutional structures jointly shape living conditions for vulnerable populations. For elderly HIV-infected individuals—a term retained in the framework acronym (AFLE-HIV) for consistency, with “older adults” used as the preferred terminology elsewhere in this paper—the environmental press is amplified by disease-specific requirements, including proximity to ART distribution centers, the necessity for privacy to avoid involuntary disclosure of serostatus, and the demand for mental health services that address both age-related cognitive decline and HIV-associated neurocognitive disorders [, ]. The World Health Organization (WHO) Age-Friendly Cities and Communities framework has provided a foundational guide for creating supportive environments for older populations []; however, this framework does not explicitly incorporate the distinctive requirements of older adults living with HIV, leaving a significant gap in both research and practice [, ].