The heart is frequently affected in patients with the acquired immune deficiency syndrome (AIDS). Although the introduction of potent antiretroviral therapy (ART) has produced a sharp decline in mortality and morbidity in HIV-infected patients, the use of ART is associated with the development of peripheral insulin resistance, dyslipidemia, and lipodystrophy. These abnormalities are also associated with coronary artery disease, and numerous reports of myocardial infarction in young HIV-infected patients have raised concerns of premature coronary disease in this population. A comprehensive review of the epidemiology of coronary artery disease is given. In recent years, several non-invasive methods to detect early development of atherosclerosis have been evaluated. Two noninvasive techniques using ultrasound have emerged as valid methods to detect early development of atherosclerosis: intima-media thickness and endothelial dysfunction assessed by the measurement of flow-mediated brachial artery dilatation. Multicenter, randomized trials using either technique may provide more information about whether HIV infection alone, long-term HAART use, or both may increase the risks of or accelerate coronary disease in HIV-infected patients.