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Background To our knowledge, no prior study has evaluated outcomes after elective lumbar spinal surgery in human immunodeficiency virus (HIV) patients without acquired immunodeficiency syndrome (AIDS). This review investigated the impact of HIV-positive status (without AIDS) on outcomes after elective lumbar fusion for degenerative disc disease (DDD). Methods Adult patients registered in the Nationwide Inpatient Sample (2002–2011) undergoing elective lumbar fusion for DDD were extracted. Multivariable regression techniques were used to explore the association of HIV positivity with outcomes after lumbar fusion. Results This cohort included 612,000 hospitalizations (0.07% were HIV positive) of lumbar fusion for DDD. Compared with HIV-negative patients undergoing lumbar fusion, HIV-positive patients were younger (47 vs. 55 years), male (61% vs. 42%), largely insured by Medicare (30% vs. 5%), and had higher rates of chronic obstructive pulmonary disease (23.7% vs. 14.6%) (all P < 0.001) but had lower rates of obesity, hypertension, and diabetes (all P < 0.001). Multivariable models demonstrated HIV positivity to be associated with higher odds for an adverse event (odds ratio [OR], 1.92; P < 0.001), in-hospital mortality (OR, 39.91; P < 0.001), wound complications (OR, 2.60; P = 0.004), respiratory (OR, 5.43; P < 0.001) and neurologic (OR, 1.96; P = 0.039) complications, and higher costs (7.1% higher; P = 0.011) compared with non-HIV patients. There were no differences in thromboembolic events, cardiac or gastrointestinal complications, discharge disposition, or length of stay. Conclusions Even in this selected cohort of well-controlled HIV patients, there were high complications, with concerning rates of death and respiratory complications. These data shed new light on elective spine surgery in HIV patients and may influence the treatment algorithm of surgeons who are familiar with older papers. [ABSTRACT FROM AUTHOR]