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Background Frailty is increasingly recognized among persons with HIV (PWH) despite effective antiretroviral therapy (ART). The Pictorial Fit-Frailty Scale (PFFS) is a rapid visual tool potentially useful for identifying individuals at risk. We evaluated the association between PFFS-defined vulnerability and patient-reported outcome (PRO) impairments in optimally treated PWH.Methods In this cross-sectional study, 108 randomly selected antiretroviral-treated PWH attending outpatient care were enrolled. Clinical, therapeutic and demographic variables were recorded. Participants underwent mini-Addenbrooke Cognitive Examination Test (MACE), Beck Depression Inventory II (BDI-II), Hamilton Anxiety Rating Scale (HAM-A), Pittsburgh Sleep Quality Index (PSQI), EQ-5D-5L (QOL), Grooved Pegboard Test (GPT) and Pictorial Fit-Frailty Scale (PFFS). Data are shown as numbers (percentage) or median (IQR).Results All participants [median age 58 (51-64) years] were on antiretroviral treatment with HIV RNA<50 copies/mL. We recorded a long HIV duration [14.3 (4.2-19.5) years] and high CD4 count [537 (400-774) cells/mm3]. Comorbidities were common, including dyslipidemia (40.0%), hypertension (37.8%), anxiety/depression disorders (24.4%), and diabetes (17.8%). Moderate/severe depressive symptoms were reported by 7 (BDI-II≥20, 6.5%) participants while moderate/severe anxiety by 30 (HAMA ≥18, 27.7%). We observed poor sleep quality (PSQI≥5) and low quality of life (EQ-5D-5L<90%) in 52 (54.2%) and 83 (84.7%) individuals. Low cognitive performance (MACE≤23) and impaired fine motor function (non dominant hand GPT≥2SD) were recorded in 23 (21.3%) and 29 (29.6%) study participants. PFFS frailty index was 0.16 (0.09-0.20) and identified 19 (17.6%) and 10 (9.3%) as moderately or severely frail: the domains mostly reported as abnormal were polypharmacy (36, 37.9%), social connections (26, 26.8%), and fatigue (13, 13.4%). Frailty index was associated with sleep quality (rho=0.413, p<0.001), depressive symptoms (rho=0.596, p<0.001), anxiety (rho=0.577, p<0.001), and quality of life (rho=-0.505, p<0.001).Conclusions In optimally treated PWH with durable virological control, the PFFS identifies individuals at increased risk of multidimensional impairment and worse patient-reported outcomes, including depression, anxiety, sleep disturbance, reduced quality of life. The PFFS may represent a practical first-line screening tool to flag patients warranting comprehensive geriatric or multidisciplinary assessment.