Objective To investigate the status and influencing factors of optimism among reproductive-aged women with human immunodeficiency virus (HIV), aiming to provide a reference for promoting the comprehensive management of female HIV patients. Methods The convenience sampling method was used to select reproductive-aged women with HIV who attended the infectious disease outpatient clinic of a designated hospital in Guangzhou from December 2023 to June 2024. General information questionnaire, Revised Life Orientation Test (LOT-R), and Medical Coping Modes Questionnaire (MCMQ) were used for the survey. Non-parametric tests and multiple linear regression analysis were conducted using SPSS 26.0 software. Results A total of 185 reproductive-aged women with HIV were included. The total LOT-R score was 22.00（19.00, 25.00） points, with the optimism dimension score being 13.00(11.00, 15.00) points and the pessimism dimension score being 9.00(7.00, 11.00) points. Multiple linear regression analysis results showed that being an only child (β=−0.151) and having changed fertility intentions due to HIV infection (β=−0.141) were negatively correlated with LOT-R scores, while place of residence (β=0.165) and having a history of childbirth (β=0.171) were positively correlated with LOT-R scores. All correlations exhibited statistical significance (P < 0.05). Conclusions The level of optimism among reproductive-aged women with HIV is moderate. Attention should be given to patients who are the only children, reside in rural areas, or have no history of childbirth. It is recommended to use family system intervention as a key entry point to alleviate the role pressure of only daughters; utilize digital tools to expand remote support to narrow the geographical and information gap for rural patients; and provide integrated psychological and medical decision-making counselling for those with fertility-related concerns, thereby comprehensively enhancing the mental health and fertility confidence of this population.