This article reviews the worldwide evolution of liver transplantation as a therapeutic intervention in HIV-infected patients. Since the introduction of highly active antiretroviral therapy (HAART), liver disease secondary to viral hepatitis has become a leading cause of morbidity and mortality among HIV-positive individuals. The authors contrast survival data from pilot studies in the pre-HAART era to those data emerging from more recent trials. Particular emphasis is placed on current selection criteria for HIV-positive transplant candidates. Additional consideration is given to the effect of prolonged transplant waiting time on survival outcome. The complexity of the post-transplant medication regime, including drug interactions, optimal immunosuppression and most appropriate HAART regimes, are discussed in detail. Postoperative challenges including optimal management of hepatitis B virus and recurrent hepatitis C virus post-transplant are reviewed separately. The ethical and practical arguments relating to the use of a scarce and valuable resource in this population are debated. The authors conclude with several recommendations to assist pretransplant assessment and postoperative management of such complex patients and speculate on the direction and evolution of this field in the coming years.