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Cognitive and motor performances decline with ageing, and this may be exacerbated in people with HIV (PWH) due to several factors. The study aimed to compare cognitive and fine motor performance between older adults with and without HIV. We conducted a cross-sectional study of participants ≥ 65 years in the GEPPO cohort using Mini-Addenbrooke's Cognitive Examination (MACE) and Grooved Pegboard Test (GPT). Quality of life, depression, anxiety, and sleep quality were also measured. PWH (n = 239) were younger (73.7 vs. 80.6 years) and more commonly males at birth (85 vs. 25%) than PWoH (n = 52). No significant differences in MACE scores were observed between groups (24 vs. 23, p > 0.900). Time to complete GPT was longer in PWoH (140 vs. 106 s, p = 0.004), with 56% exceeding normative GPT values vs. 24% in PWH (p < 0.001). In multivariate models, older age and lower education predicted worse MACE and GPT scores, whereas benzodiazepine/Z drug use predicted poorer fine motor skills. PWH reported lower quality of life but similar or better depression, anxiety, and sleep scores compared to PWoH. Older PWH show comparable cognitive but better fine motor performance than PWoH. Education and benzodiazepine use emerged as key modifiable or protective factors, underscoring the importance of targeted geriatric and mental health interventions.