BACKGROUND Hepatic cystic echinococcosis (HCE) appears more severe in human immunodeficiency virus (HIV) co-infected (HIV+) patients with a more complicated clinical presentation (larger, multifocal cysts, biliary obstruction, secondary infection, cyst rupture), often necessitating urgent treatment with higher post-operative complications. This case-cohort study compared HCE treatment outcomes in HIV+ and HIV negative (HIV-) patients. METHODS Patients with known HIV status who underwent HCE surgery at our tertiary institution between 2011 and 2023 were assessed for pre-, intra-, and post-operative outcomes. Surgical complications were compared using the Accordion severity scores. RESULTS The majority of the 87 operated patients were HIV+ (51.7 %). Complication rates were comparable between the HIV+ and HIV- groups with similar Accordion severity scores. Cholangitis was statistically less frequent in HIV+ (6.7 %) vs. HIV- patients (26.2 %), p = 0.019. Cyst infection rates were lower in HIV+ (20.0 %) than in HIV- (38.1 %) patients. Five HIV+ and three HIV- patients required re-operation. Mortality occurred in two HIV+ and five HIV- patients. CONCLUSIONS Although outcomes were similar, the disproportionately high number of HIV+ patients (51.7 %) compared to the general population HIV prevalence (12.7 %) suggests that HCE is less self-limiting with HIV co-infection, supporting a potential link between co-infection and severity of disease presentation.