Background: HIV is associated with an increased risk of cardiovascular disease (CVD) and related clinical events. While traditional risk factors play an important role in the pathology of cardiovascular disease, HIV infection and its sequelae of immune activation and inflammation may have significant effects on the myocardium before becoming clinically evident. Cardiac MRI (CMR) can be used to detect the pattern of these subclinical changes. This will lead to a better understanding of risk factors contributing to cardiovascular disease prior to it becoming clinically significant in HIV-positive patients. Methods: Prospective cohort study of 127 asymptomatic HIV-positive men on ART compared to 35 matched controls. Baseline demographics, HIV parameters, 12-lead ECG, routine biochemistry, and traditional cardiovascular risk factors were recorded. Images were acquired on a 3T Achieva Philips MRI scanner with 5 channel phase array cardiac coil and weight-based IV gadolinium was given at 0.15 mmol/kg dose with post-contrast inversion recovery imaging after 10 minutes. Results: 6/127 (4.7%) of asymptomatic HIV-positive men had late gadolinium enhancement (LGE) on MRI verses 1/35 (2.9%) in the control group. In 3/6 (50%) of cases this was in a classical infarction pattern with subendocardial involvement. 3/6 (50%) were consistent with prior myocarditis. There was no significant difference in mean LVEF (66.93% vs 65.18%), LVMI (60.05g/m2 vs 55.94g/m2) or posterolateral wall thickness (8.28 mm and 8.16 mm) between cases and controls respectively. There was significantly more diastolic dysfunction, E:A ratio < 1, found in the HIV-positive group, 18% vs 7% of controls (p = 0.037). Framingham risk did not predict either of these outcomes. Conclusions: There is an increased incidence of LGE detected on CMR in this asymptomatic HIV-positive cohort. Two distinct pathological processes were identifed as causing these changes, myocardial infarction and myocarditis. These findings were independent of traditional cardiac risk factors, duration of HIV infection and ART therapy. Sub clinical cardiac dysfunction may be underreported in other cardiac evaluation studies. The true impact of other potential risk factors may also be underestimated, highlighting the need for the development of more complex prediction models.