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Background Liver transplantation (LT) is nowadays increasingly feasible in people with HIV, yet knowledge on long-term outcomes is limited. This study aims to provide a two-decade experience on people with HIV undergoing LT compared to non-HIV recipients.Methods Retrospective matched case–control study including all recipients with HIV (RWH) who consecutively underwent LT at the University Hospital of Modena between 2003 and 2024. Each RWH was matched 1:3 with non-HIV recipients using a propensity-score model based on age, sex, MELD, presence of hepatocellular carcinoma (HCC) at transplant, HBV and/or HCV co-infection, and donor age. Long-term graft and recipients’ survival, occurrence of acute rejection (AR) and HCC recurrence were evaluated using Kaplan-Meier curves. Predictors of AR were explored using logistic regression.Results Eighty-seven liver RWH were included: 88% with history of drug injections, 20% with previous opportunistic infections and a median HIV duration of 25 years (IQR 20-31); at transplant, 95.4% had undetectable HIV RNA with CD4 cell count of 278 cell/mm3 (IQR 201-405). RWH were matched with 261 non-HIV recipients. Baseline characteristics were comparable (median age 53 years, IQR 47-58; 17% females) except for higher prevalence of HCV co-infection among RWH versus non-HIV recipients (93.1% vs 66.7%, p<0.01). Ten-year and 15-year graft survival was 78.7% and 60.1% in RWH vs 81.6% and 72.6% in non-HIV recipients, respectively ( figure 1a); the overall recipients’ survival was also comparable both at 10 years (59.6% vs 66.7%) and 15 years (48.9% vs 53.1%) (figure 1b). HCC recurred in 10% of cases in both groups, with a post-transplant IR of 1.8 (95% CI 1.0-3.5) in HIV vs 1.4 (95% CI 1.0-2.1) in non-HIV per 100 PYFU (p=0.519), although time to recurrence tended to be longer in HIV recipients [2.4 (IQR 1.2-6.7) vs 0.8 (IQR 0.6-1.6) years, p=0.06]. Recurrent HCC reduced significantly survival compared (p <0.001), without difference according to HIV serostatus (p=0.426) (figure 2a-b).The incidence rate (IR) of AR was 5.5 (95% CI 3.3-9.3) in RWH vs 0.8 (95% CI 0.5-1.2) in non-HIV per 100 PYFU. Among transplants performed after 2015, 1-year rejection IR decreased to 1.1 (95% CI 0.3-4.6) in RWH vs 0.9 (95% CI 0.2-3.9) in non-HIV recipients per 100 PYFU (figure 3a-b). Predictors of rejection were HIV infection (aOR 2.43, 95%CI 1.10-5.32), CMV infection/reactivation (aOR 3.25, 95%CI 1.25-8.47), and active HCV infection (aOR 2.40, 95%CI 1.10-5.24); after 2015, only CMV infection/reactivation was associated to rejection (table 1).Conclusion LT in HIV achieves good long-term outcomes comparable to non-HIV recipients. After 2015, thanks to the advent of effective anti-HCV treatment and the disuse of protease inhibitors, HIV infection was no more associated to higher risk of rejection. HCC recurred in about 10%, without any difference between HIV and non-HIV, though impacting on survival even after HCV eradication.Abstract OC12 Figure 1–3Abstract OC12 Table 1Predictors of acute rejection overall and in liver recipients after 2015