Purpose of Review <p>This review synthesises current evidence on the cardiovascular disease (CVD) burden among young people living with HIV. It explores myocardial and vascular pathology, evaluates the role of advanced imaging, and highlights critical gaps in understanding the mechanisms driving HIV-associated CVD in this population.</p> Recent Findings <p>Emerging data suggest that HIV-associated CVD in youth may be predominantly driven by non-atherosclerotic mechanisms, including direct myocardial injury, fibrosis, and remodelling, rather than traditional coronary atherosclerosis. Imaging studies have revealed subclinical myocardial changes such as increased left ventricular mass and reduced strain. Vascular studies show inconsistent findings. However, longitudinal data and multimodal imaging approaches remain scarce, particularly in high-burden regions like Africa.</p> Summary <p>Young adults with HIV face a significant burden of cardiovascular pathology, often subclinical and poorly understood. The prevailing paradigm focused on atherosclerosis may not fully apply to this group, especially in African settings. There is an urgent need for longitudinal, mechanistic research to inform tailored clinical strategies and policy interventions aimed at reducing long-term cardiovascular morbidity in young people with HIV.</p>