Before effective antiretroviral treatment was introduced in children with HIV, cardiovascular complications were a major cause of morbidity and mortality. Now that antiretroviral treatment is the standard of care in this population, there has been a shift from fulminant cardiovascular complications to recognition of cardiovascular issues related to HIV as a chronic disease state and its treatment. This review explores the recent advances in understanding the roles of atherosclerosis, inflammation, biomarkers, and metabolic abnormalities in cardiac function and cardiovascular disease risk in children with HIV. The true risk and prevalence of cardiovascular outcomes in HIV-infected children and adolescents has yet to be realized. Recently, however, investigators are exploring new cardiovascular health challenges that face children living with HIV, and developing strategies to lower the cardiovascular disease risk for these children.