Cardiovascular disease (CVD), with atherosclerosis as the major underlying factor, remains the leading cause of death worldwide. It is well established that cholesterol ester-enriched foam cells are the hallmark of atherosclerotic plaques. Multiple lines of evidence support that enhancing foam cell cholesterol efflux by high density lipoprotein (HDL) particles, the first step of reverse cholesterol transport (RCT), is a promising antiatherogenic strategy. Yet, excitement towards the therapeutic potential of manipulating RCT for the treatment of CVD has faded because of the lack of the association between CVD risk and what was typically measured in intervention trials, namely HDL cholesterol (HDL-C), which has an inconsistent relationship to HDL function and RCT. In this review, we will summarize some of the reasons for this inconsistency, update the mechanisms of RCT, and highlight conditions in which impaired HDL function or RCT contributes to vascular disease. On balance, the evidence still argues for further research to better understand how HDL functionality contributes to RCT in order to develop prevention and treatment strategies to reduce the risk of CVD.