Human immunodeficiency virus (HIV) infection continues to be a vexing problem in the pediatric population. Otitis media, a common entity in immunocompetent as well as immunocompromised children, is prevalent in pediatric patients with HIV infection. Recurrent infections and complications secondary to otitis media are also common in this population. The purpose of this review was to evaluate the records of a large group of children with HIV infection undergoing treatment for otitis media at a tertiary care center. Incidence of infections, severity of infections, and pathogens responsible were the key points of data collection in relation to each patient's HIV clinical and immunologic classification. We reviewed 72 patients with vertically-acquired HIV infection undergoing treatment at the Hospital for Sick Children, Great Ormond Street, London. All patients were born to HIV infected mothers of sub-Saharan African origin. A total of 32 (44.4%) of these children presented to our institution with one or more episodes of otitis media, six of whom suffered systemic complications secondary to middle ear pathology. Middle ear culture data, when available from actively draining ears, was similar to those of immunocompetent children in the general population. The most common complications were systemic bacteremia and recalcitrant infections requiring intravenous antibiotic therapy. Severity of immunosuppression was associated with higher incidence and severity of otitis media. Otitis media in an HIV infected child must be treated aggressively at its outset in an attempt to minimize possible complications. Administration of prophylactic antibiotics to these children may reduce the frequency of acute and chronic infections. Improvement in immunologic status using antiretrovirals or protease inhibitors is a primary goal in diminishing the severity of otitis media as well as other infections in these children.