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Cumulative evidence to date largely supports an association between dysregulation of the activity of the hypothalamic-pituitary-adrenal (HPA) axis and fatigue. People living with HIV (PLHIV), in particular, are vulnerable to both HPA axis dysregulation and fatigue. Few investigations have examined the possible role of HPA-axis dysfunction in the occurrence of fatigue in PLHIV. This cross-sectional study aimed to investigate the association between glucocorticoids in hair, retrospective indicators of long-term HPA axis activity and biomarkers of chronic stress, and fatigue in PLHIV. A total of 446 PLHIV from Guangxi China provided hair samples for cortisol and cortisone assay and provided information on fatigue levels, sociodemographic, lifestyle, and HIV-related characteristics. Results showed that before and after controlling sociodemographic, lifestyle, and HIV-related characteristics, hair cortisone levels, but not hair cortisol levels, were associated with fatigue levels in PLHIV. In conclusion, we found that higher cortisone levels are associated with greater fatigue levels in a large cohort of Chinese PLHIV. We found that hair cortisone levels were significantly associated with fatigue levels in a large cohort of Chinese PLHIV. Hair cortisol levels were, however, not associated with fatigue levels in the PLHIV studied. We thus show that Chinese PLHIV who have higher cortisone levels are associated with higher fatigue levels. [ABSTRACT FROM AUTHOR]