During the first COVID-19 wave in Zambia, PLHIV were more likely to be acutely infected with SARS-CoV-2 (as measured by PCR) but less likely to have a prior infection (as measured by ELISA). This could be due to a poorer humoral immune response to SARS-CoV-2 antigens in PLHIV. Ensuring early access to COVID-19 vaccinations, testing and ART might reduce COVID-19 morbidity among PLHIV.