Purpose: To describe the clinical presentation, ocular complications and clinical implications of acute HZO in HIV positive patients. Method: Prospective descriptive clinical case series of 54 individuals aged 18 – 50 years with confirmed HIV infection and acute presentation of HZO. Results: A female preponderance (1.7:1) and mean age of 36.6 years (range 18 – 49 years) was recorded. The majority of patients were referred from CHC and only 28% of referred patients received appropriate antiviral treatment at the referral site. Mean duration of rash at presentation was 4.7 days (range 1 – 12 days) with 31% of patients presenting within 3 days of rash eruption. Patients attended a mean of 2.7 clinical visits. Equal proportions had known and unknown HIV serostatus at presentation. Mean CD4+ was 276 cells/mm3 (range 44 - 859 cells/mm3). 67% of patients had a CD4+ count < 350 cells/mm3. Periocular discomfort was the most common presenting symptom (70%); decreased VA (2%) was an uncommon presenting symptom. Multidermatomal involvement was uncommon (7%). At presentation normal VA was seen in 69% of patients and 94% had no global visual impairment. Corneal complications (89%) and intraocular inflammation (46%) were the most common ocular complications. Ocular complications at presentation and multiple complications were the rule (70% and 61%). Hutchinson sign was found to be of little clinical value. Visual outcome was fair, 22% of patients having residual visual impairment. Post-herpetic neuralgia was common (74%). Conclusion: HZO is a common HIV marker condition with ocular complications. It may have an application as an indication for the initiation of ARV treatment.