Women with HIV had a significantly higher adjusted hazard ratio for CVD compared to their matched counterparts without HIV than men with HIV, and this elevated risk persisted despite viral suppression or preserved immune function.
Key Findings
Results
Women with HIV had a greater elevated risk of incident CVD compared to women without HIV than men with HIV had compared to men without HIV.
Women with HIV had an adjusted hazard ratio (aHR) for CVD of 1.933 (95% CI: 1.709–2.188) compared to matched women without HIV.
Men with HIV had an aHR of 1.435 (95% CI: 1.313–1.568) compared to matched men without HIV.
Cox proportional hazards models included an interaction term between sex and HIV status to assess sex differences.
The study used a retrospective cohort design with propensity score matching (1:5) by sex, age, and race/ethnicity from the All of Us Research Program.
Results
Women with HIV remained at significantly higher risk of CVD compared to women without HIV even when viral suppression was achieved.
Among women with HIV who achieved viral suppression (HIV RNA < 50 copies/ml), the aHR for CVD compared to women without HIV was 1.929 (95% CI: 1.565–2.378).
This indicates that viral suppression did not eliminate the excess CVD risk in women with HIV.
The finding suggests that factors beyond viral replication contribute to CVD risk in women with HIV.
Results
Women with HIV remained at significantly higher risk of CVD compared to women without HIV even when immune function was preserved.
Among women with HIV with preserved immune function (CD4+ cell count >500 cells/μl), the aHR for CVD compared to women without HIV was 1.813 (95% CI: 1.455–2.259).
This indicates that preserved immune function did not eliminate the excess CVD risk in women with HIV.
The subgroup analyses evaluated effect modification by both viral suppression and preserved immune function.
Results
No significant difference in CVD risk was observed between men with well-controlled HIV and men without HIV.
Among men with HIV and well-controlled disease, the aHR for CVD compared to men without HIV was 1.133 (95% CI: 0.964–1.332), which was not statistically significant.
This contrasts sharply with the persistent elevated risk observed in women with HIV under similar conditions of disease control.
The definition of well-controlled HIV used in this subgroup is not explicitly stated but corresponds to the viral suppression and/or immune function subgroups.
Methods
The matched analytic cohort comprised 4803 people with HIV (PWH) and 24,276 people without HIV (PWoH), all free of preexisting CVD.
Propensity score matching was performed at a 1:5 ratio (PWH to PWoH), matching on sex, age, and race/ethnicity.
Data were drawn from electronic health records in the All of Us (AoU) Research Program.
The cohort was restricted to participants who were free of CVD before the index date to assess incident CVD.
This was a retrospective cohort study design.
What This Means
This research suggests that HIV infection raises the risk of heart and cardiovascular disease (CVD) in both men and women, but the excess risk is substantially greater for women. Using health records from over 29,000 people — some living with HIV and others not — researchers found that women with HIV were about 93% more likely to develop CVD than women without HIV, while men with HIV were about 44% more likely than men without HIV. This sex difference in cardiovascular risk was a key finding of the study.
Perhaps most striking, this research suggests that even when women with HIV had their virus well-controlled (low viral levels in the blood) or had healthy immune cell counts, they still faced a much higher risk of CVD compared to women without HIV — roughly 80–93% higher risk. In contrast, men with HIV who had well-controlled disease showed no statistically significant increase in CVD risk compared to men without HIV. This implies that for women living with HIV, factors beyond viral replication and immune suppression are driving their elevated cardiovascular risk.
These findings matter because they highlight that standard HIV treatment success — suppressing the virus and maintaining immune health — may not be sufficient to protect women with HIV from heart disease. This research suggests that clinicians and researchers may need to investigate sex-specific biological or social factors contributing to CVD in women with HIV, and that targeted cardiovascular prevention strategies for this population are warranted.
Fanghui Shi, Huiyi Xia, Sharon Weissman, Xiaoming Li, Xueying Yang. (2026). Sex differences in cardiovascular disease in people with and without HIV.. AIDS (London). https://doi.org/10.1097/QAD.0000000000004567