BACKGROUND: The effect of HIV on blood pressure (BP) trajectory is not fully understood, especially in sub-Saharan Africa. We describe longitudinal BP trajectories and their association with subclinical cardiac dysfunction and structure among HIV-infected and HIV-uninfected adults in Tanzania. METHODS: This analysis included 423 people living with HIV (PLWH) and 464 HIV-uninfected controls from a prospective cohort study. Every participant had ≥3 BP measurements and an echocardiogram. Group-based multitrajectory modeling identified groupings based jointly on longitudinal systolic and diastolic BP. Multivariable multinomial logistic regression determined the association between HIV status and BP trajectory group. Multivariable linear regression evaluated the association between BP trajectory group and average E/e', left atrial volume index, and left ventricular mass index. RESULTS: The mean age of the cohort was 36.0±10.1 years; 68.3% were women. Participants were followed for an average of 2.8±1.3 years. Four BP trajectory groups were identified: low-normal (mean systolic BP/diastolic BP, 99/66 mm Hg), normal (mean systolic BP/diastolic BP, 112/71 mm Hg), elevated (mean systolic BP/diastolic BP, 128/82 mm Hg), and high (mean systolic BP/diastolic BP, 141/85 mm Hg). PLWH had higher odds of classification to the low-normal trajectory (adjusted odds ratio, 1.92 [95% CI, 1.09-3.37]) and lower odds of classification to the elevated (adjusted odds ratio, 0.56 [95% CI, 0.39-0.79]) or high trajectory groups (adjusted odds ratio, 0.41 [95% CI, 0.26-0.64]) compared with HIV-uninfected participants. HIV was associated with higher left atrial volume index and left ventricular mass index after adjustment for age, sex, cardiovascular disease risk factors, and BP trajectory group. In participants classified to the high trajectory group, the prevalence of left ventricular hypertrophy was 35.9% among PLWH and 18.8% among controls. CONCLUSIONS: PLWH had lower average BP trajectories than HIV-uninfected participants in the initial years after antiretroviral therapy initiation. Within BP trajectory groups, PLWH had increased left atrial volume index and left ventricular mass index. Early screening for hypertension in sub-Saharan Africa is paramount for CVD prevention, especially among PLWH, who may develop CVD at lower BP levels.