Objectives: We investigated occurrence of and risk factors for severe COVID-19 outcomes in PWH in the Netherlands. Design: Ongoing prospective nationwide HIV cohort study. Methods: COVID-19 diagnoses and outcomes with other relevant medical information were prospectively collected from electronic medical records in all HIV treatment centers in the Netherlands, from the start of the COVID-19 epidemic until 31 December 2021. Risk factors for COVID-19 related hospitalization and death were investigated using multivariable logistic regression, including demographics, HIV-related factors, and comorbidities. Results: The cohort comprises 21,289 adult PWH, median age 51.2 years, 82% male, 70% were of Western origin, 12.0% were of sub-Saharan African and 12.6% Latin American / Caribbean origin, 96.8% had HIV-RNA <200 copies/mL, median CD4 count 690 (IQR 510–908) cells/mm 3 . Primary SARS-CoV-2 infections were registered in 2,301 individuals, of whom 157 (6.8%) required hospitalization and 27 (1.2%) ICU admission. Mortality rates were 13% and 0.4% amongst hospitalized and non-hospitalized individuals, respectively. Independent risk factors for severe outcomes (COVID-19-related hospitalization and death) were higher age, having multiple comorbidities, a CD4 count <200 cells/mm 3 , uncontrolled HIV replication and prior AIDS diagnosis. Migrants from sub-Saharan Africa, Latin America and the Caribbean were at increased risk of severe outcomes independently of other risk factors. Conclusions: In our national cohort of PWH, risk of severe COVID-19 outcomes was increased in individuals with uncontrolled HIV replication, low CD4 count and prior AIDS diagnosis, independently of general risk factors like higher age, comorbidity burden and migrants originating from non-Western countries.