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To assess the prevalence of elevated blood pressure in patients with lipodystrophy.Case–control study.Forty-two patients with abnormal body fat (100%) and serum lipids (86%) (HIV-positive cohort) were matched by age and sex to 42 HIV-positive controls without previously diagnosed lipodystrophy and to 13 HIV-negative controls.Tertiary care, university-based, fully dedicated HIV clinic.Frequency and magnitude of elevated blood pressure during highly active antiretroviral therapy.There were 23 ± 16 and 22 ± 12 blood pressure measurements recorded per subject over 21 ± 11 and 22 ± 11 months for the HIV-positive cohort and HIV-positive controls, respectively. Three or more elevated readings occurred in 74% of the cohort and in 48% of the HIV-positive controls (P = 0.01) and accounted for 38 ± 25% versus 22 ± 26% (P = 0.01) of the total readings, respectively. The average of the three highest systolic readings (153 ± 17 versus 144 ± 15 mmHg;P = 0.01) and diastolic readings (92 ± 10 versus 87 ± 9 mmHg;P = 0.01) was greater for the cohort than for the HIV-positive controls. Family history of hypertension was more common in the cohort than in the controls but accounted for only 13% of the log odds ratio value for elevated blood pressure in the cohort. Systolic blood pressure was correlated with waist-to-hip ratios in the cohort (r = 0.45;P = 0.003) but not in the HIV controls (r = 0.06;P = 0.68) and tended to be related to fasting triglycerides (r = 0.34;P = 0.052) in subjects with HIV.Elevated blood pressure may be linked to the metabolic disorders occurring in patients with HIV, as in the dysmetabolic syndrome.