Around 225,000 patients currently receive antiretroviral therapy (ART) in the Malawi scale-up programme that uses the public health approach to ART. There are concerns that cardiovascular disease risk factors are common in ART patients, but few data exist from sub-Saharan Africa, and none from Malawi. We did a cross-sectional study of cardiovascular risk factors in urban, adult, Malawian ART patients, with the WHO STEP-wise surveillance tool. We enrolled 174 long-term (>1 year) ART patients during routine clinic visits, mean age 40.8 years (range 18-69), 61.5% female, 97.1% on first-line regimens, median duration ART 35.5 months. Insufficient fruit and vegetable diet (67.6%), raised blood pressure (45.9%), increased waist-hip ratio (45.4%), raised total cholesterol levels (31.0%) and low physical activity level (27.0%) were common, while current smoking (0.6%), current alcohol consumption (2.3%) and elevated glucose levels (1.2%) were rare. In multivariable analyses, higher age was associated with low physical activity, raised blood pressure, being overweight, and increased waist-hip ratio. Longer duration of ART was not associated with any risk factor and was protective for being overweight. Cardiovascular risk factors were common among long-term ART patients in Malawi. This requires more attention and further study in programmes using the public health approach to ART.