We performed a cross-sectional analysis of factors associated with negative body image among 550 older men with or at-risk for HIV infection, including demographics, depression, illicit drug use, and antiretroviral therapy adherence. Overall, 31 per cent of participants reported negative body image, which was independently associated with increased BMI, self-rated fair/poor health, depression, and erectile dysfunction, but not HIV status. Screening for and treating depression, sexual dysfunction, and obesity in older men should be considered.