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Sex differences in cardiovascular
disease in people with and without HIV
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nov 2026
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Consistent with prior studies, both women with HIV and men with HIV had a higher risk of CVD than their seronegative counterparts . Our findings further suggest that the relative burden of CVD may be greater among women with HIV than among men with HIV, even among those with virological suppression and preserved immune function. This finding extends the current literature by indicating that excess CVD risk may persist in women with HIV despite favorable HIV-related clinical indicators. These results underscore the need for early and targeted prevention and treatment strategies to reduce CVD risk among women with HIV.
Women with HIV are at a greater risk of CVD than men with HIV, even after adjusting for certain traditional CVD risk factors and other comorbid conditions . Specifically, women with HIV had a 1.933 times higher risk of CVD than women without HIV, while men with HIV had a 1.435-fold higher risk than men without HIV, aligning with previous research showing a general 1.5-2.0-fold increase in the risk of CVD among PWH compared to PWoH .
Despite achieving virological suppression and preserved immune function, women with HIV were still at a higher risk of CVD compared to women without HIV. PWH undergoing ART often experience lingering systemic inflammation, which has been linked to an increased risk for CVD due to its role in promoting atherosclerosis.
The elevated CVD risk among women with HIV could also be partially explained by menopause experienced by older women.
Subgroup analyses showed that this elevated risk persisted even among PWH with high CD4+ cell counts (CD4+ cell count >500 cells/μl) (aHR = 1.468, 95% CI: 1.284-1.678) and suppressed viral load (HIV RNA < 50 copies/ml) (aHR = 1.355, 95% CI: 1.190-1.543), when comparing to PWoH.
Several other risk factors for CVD were identified, including unemployment status (aHR = 1.375, 95% CI: 1.277-1.480), diabetes (aHR = 1.321, 95% CI: 1.136-1.537), hypertension (aHR = 1.241, 95% CI: 1.086-1.418), renal disease (aHR = 2.128, 95% CI: 1.778-2.548], liver disease (aHR = 1.251, 95% CI: 1.030-1.520), hyperlipidemia (aHR = 1.241, 95% CI: 1.086-1.418), obesity (aHR = 1.293, 95% CI: 1.185-1.411), and alcohol use disorder (aHR = 1.263, 95% CI: 1.053-1.516) (Table 2).
Objective:
This study aims to assess the association between HIV infection and cardiovascular disease (CVD) incidence, with a focus on sex differences and the role of immune status.
Design:
Retrospective cohort study using electronic health records from the All of Us (AoU) Research Program. We identified people with HIV (PWH) and matched them to people without HIV (PWoH) using propensity score matching (PSM) (1 : 5) by sex, age, and race/ethnicity. The matched cohort was then restricted to participants who were free of CVD before the index date.
Methods:
We used Cox proportional hazards models, including an interaction term between sex and HIV status, to assess sex differences in the association between HIV status and incident CVD, adjusting for potential confounders. Subgroup analyses evaluated effect modification by viral suppression (HIV RNA < 50 copies/ml) and preserved immune function (CD4+ cell count >500 cells/μl).
Results:
After PSM, we identified 4803 PWH without preexisting CVD and matched them with 24 276 PWoH. Compared to their matched PWoH, women with HIV had an elevated adjusted hazard ratio (aHR) for CVD [aHR = 1.933, 95% confidence interval (CI): 1.709-2.188] than men with HIV (aHR = 1.435, 95% CI: 1.313-1.568). In subgroup analyses, compared with women without HIV, women with HIV remained at higher risk of CVD despite viral suppression (aHR = 1.929, 95% CI: 1.565-2.378) or preserved immune function (aHR = 1.813, 95% CI: 1.455-2.259). In contrast, no significant differences were observed between men with HIV and well controlled men without HIV (aHR = 1.133, 95% CI: 0.964-1.332).
Conclusion:
Understanding sex-specific drivers of CVD risk is crucial for developing targeted interventions to prevent CVD in women with HIV and men with HIV.
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