A comprehensive study of 1,508 South Africans found that women living with HIV on antiretroviral therapy face nearly double the risk of developing heart failure with preserved ejection fraction (HFpEF) compared to HIV-negative women. The research revealed that HIV-positive individuals had 2.1 times higher odds of elevated left ventricular mass and 1.4 times higher odds of diastolic dysfunction, with women bearing the heaviest burden. This gender disparity represents a critical finding, as 8% of the cohort had undiagnosed HFpEF, making it the predominant heart failure phenotype in this population. The results challenge assumptions about HIV-related cardiovascular disease, which in high-income countries primarily manifests as atherosclerotic disease rather than heart failure. The study's strength lies in its large community-based design and comprehensive cardiac assessment, though as a preprint awaiting peer review, these findings require validation. The research suggests that HIV's cardiovascular impact varies dramatically by geography and gender, potentially due to different viral strains, treatment patterns, or co-morbidity profiles in sub-Saharan Africa. This represents paradigm-shifting evidence for targeted cardiovascular screening in HIV-positive women.