OBJECTIVE: To understand the relationship between cardiovascular disease (CVD) risk and liver steatosis and fibrosis among people living with HIV (PLWH) ≥40 years on antiretroviral therapy (ART) in low- and middle-income countries (LMIC). DESIGN: We used cross-sectional behavioral and clinical data collected during study enrollment visits in 2020-2022 for the Sentinel Research Network of International epidemiology Databases to Evaluate AIDS (SRN of IeDEA). METHODS: Ten-year CVD risk was calculated using 2019 World Health Organization non-laboratory and laboratory models. Transient elastography (TE) was used to assess liver disease. Presence of steatosis and significant fibrosis were defined by Controlled Attenuation Parameter (CAP) ≥248 dB/m and liver stiffness measurement (LSM) ≥7.1 kPa, respectively. Participants with viral hepatitis, hazardous alcohol consumption and unsuppressed HIV viral load were excluded from the analysis. Logistic regression was used to estimate odds ratios, adjusting for study site, CD4 T cell count, stavudine and didanosine exposure, and in models stratified by sex and geographic region. RESULTS: There were 1,750 participants from nine LMIC. Median CVD risk was 3% for both non-laboratory and laboratory-based models. Adjusted odds ratios (ORs) for steatosis and significant fibrosis associated with laboratory CVD risk (≥10% vs. <5%) were OR = 1.83 (95% confidence interval:(CI) = 1.21-2.76; P = 0.004) and OR = 1.62 (95% CI = 0.85-3.07; P = 0.14), respectively. Associations of CVD risk with steatosis were stronger in males and among participants at study sites outside Africa. CONCLUSIONS: Higher CVD risk was associated with steatosis but not with significant fibrosis in PLWH in our LMIC cohort.Read less <