The pericardium, myocardium, coronary arteries and pulmonary arteries are the main targets for cardiac disease in people who are infected with HIV. Geography and access to highly active anti-retroviral therapy (HAART) have a major influence on which of these targets is affected. In sub-Saharan Africa, where tuberculosis is endemic and access to HAART is limited, the dominant forms of HIV-associated heart disease are pericardial tuberculosis and cardiomyopathy. However, in industrialized countries, where tuberculosis is rare and HAART is widely available, coronary artery disease is the main cause of death and disability in these patients. Observational data suggest that HAART, by preserving immune function, reduces the incidence of myopericardial disease and pulmonary hypertension. The result has been that, although optimal strategies to reduce vascular disease in this population continue to be sought and debated in industrialized nations, the focus of prevention and treatment strategies for HIV-related heart disease in developing countries has been to support the active campaigns to get universal access to HAART in the first place. Herein, we review the cardiac manifestations of HIV in sub-Saharan Africa.