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Erectile dysfunction (ED) is more prevalent in men living with HIV (MLHIV) when compared with age-matched HIV-negative men. This may be related to a premature decline in testosterone levels. In the general population, ED has been associated with an increased risk for coronary heart disease (CHD).The aim of this study is to determine the prevalence of ED, testosterone deficiency, and risk of CHD in a cohort of young to middle-aged MLHIV in Belgium.A cross-sectional, observational study among 244 MLHIV attending the outpatient clinic of the Institute of Tropical Medicine in Antwerp.The short version of the international index of erectile function (IIEF-5) questionnaire diagnosed ED (cutoff score ≤21). The 10-year risk score for CHD was calculated. In a subset of men reporting ED, the calculated free testosterone (CFT) was determined using Vermeulen's formula. Testosterone deficiency was defined as CFT <0.22 nmol/L.One hundred fifty-one men (61.9%) self-reported ED (median IIEF-5 score: 16 [interquartile range (IQR) 12–19]). In multivariate analysis, only increasing age, but none of the HIV-related parameters, nor any of the individual cardiovascular-risk related parameters, was statistically significantly associated with ED. Eighteen out of the 49 (36.7%) men with ED who received a blood test to assess testosterone levels were diagnosed with testosterone deficiency. The 10-year risk of CHD in the cohort was 4.3% (IQR 3.6–5.7) and was significantly higher in men with ED (5.1%, IQR 4.4–6.6) compared with men without ED (3.1%, IQR 2.5–4.2).This study showed that ED and testosterone deficiency are highly prevalent in young to middle-aged MLHIV and that ED might be associated with an increased risk of CHD. Therefore, healthcare professionals should screen for clinical ED and should consider testing for underlying testosterone deficiency. A clinical diagnosis of ED should trigger a full evaluation of the patient's cardiovascular risk factors, even at younger age. De Ryck I, Van Laeken D, Apers L, and Colebunders R. Erectile dysfunction, testosterone deficiency, and risk of coronary heart disease in a cohort of men living with HIV in Belgium. J Sex Med 2013;10:1816–1822.