PURPOSE: Anorectal disease is commonly found in human immunodeficiency virus (HIV)-infected patients. The aim of this study was to determine the spectrum of anorectal disease, its surgical treatment, clinical outcome, and its relation to immune status. METHODS: Medical records of all HIV-infected patients with anorectal pathology that required surgical treatment from January 1984 to January 1994 were retrospectively reviewed. Patients were divided into five different groups: common anorectal pathology (hemorrhoids, polyps, Group A); condylomata acuminata (Group B); perianal sepsis (abscesses, fistulas, Group C); anorectal ulcers (Group D); malignancies (Group E). RESULTS: Eighty-three patients needed 204 surgical consultations (13 percent conservative, 87 percent operative) for 170 anorectal diseases. Fifty-one patients had multiple anorectal pathology. Operative intervention resulted in adequate wound healing and symptom relief in 59 percent of patients, adequate wound healing without relief of symptoms in 24 percent of patients, and disturbed wound healing in 17 percent of patients. Disturbed wound healing was related to type of anorectal disease (P<0.001) and to preoperative CD4+-lymphocyte counts (P<0.01). Disturbed wound healing and most insufficient immune status were encountered in Groups C, D, and E. Within these groups low CD4+-lymphocyte counts were a risk factor for disturbed wound healing (P=0.004). Median postoperative survival was highest (4.7 years) in Group A, lowest (0.6 years) in Groups D and E, and related to type of anorectal disease (P=0.0001). CONCLUSIONS: The spectrum of anorectal disease is complex. Type of anorectal disease is strongly related to immune status, wound healing, and postoperative survival.