Cardiac disease in the setting of HIV/AIDS has only recently been appreciated. The pathogenesis is multifactorial including direct toxic effects, viruses, autoimmunity, nutritional deficiencies and drugs. The clinical manifestations include pericardial, myocardial and valvular heart disease. Lipodystrophy, caused by anti-retroviral therapy is common and may be a risk factor in ischemic heart disease. The treatment of lipodystrophy is reviewed in detail.