This study aimed to evaluate cerebral blood flow (CBF) in pediatric human immunodeficiency virus (HIV)-infection, and its role in HIVrelated cerebral injury and cognitive impairment. This cross-sectional observational study compared 28 perinatally HIV-infected children (8-18 years) to 34 healthy controls matched for age, sex, ethnicity, and socio-economic status. All participants underwent 3-Tesla magnetic resonance imaging, using arterial spin labeling to assess CBF in gray matter (GM), white matter (WM), basal ganglia, and thalamus. We used linear regression analysis to evaluate group differences and associations with HIV disease and treatment characteristics, macrostructural (volume loss, WM lesions) or microstructural injury (increased WM diffusivity, neurometabolite alterations), or poorer cognitive performance. HIV-infected children had higher CBF in WM (+10.2%; P=0.042), caudate nucleus (+4.8%; P=0.002), putamen (+3.6%; P= 0.017), nucleus accumbens (+3.9%; P=0.031), and thalamus (+5.5%; P=0.032). Thalamus CBF was highest in children with a Centers for Disease Control and Prevention stage B (Coef.=6.45; P=0.005) or C (Coef.=8.52; P=0.001) diagnosis. LowerGMCBF was associated with higher WM lesion volume in HIV-infected children (Coef.=-0.053; P=0.001). No further associations with HIVrelated cognitive impairment or cerebral injury were found. CBF was higher in WM, basal ganglia, and thalamus in combination antiretroviral therapy (cART)-treated perinatally HIV-infected children, but this was not associated with cerebral injury or cognitive impairment. HIV-infected children with lower GM CBF had a higher volume of WM lesions, which could reflect vascular disease as potential contributing factor to white matter injury. Lifelong exposure to HIV and cART in this population warrants longitudinal assessment of CBF and how it relates to (neuro)inflammation, vascular dysfunction, and cerebral injury in pediatric HIV.