The long-term impact of highly active antiretroviral therapy (HAART) in AIDS patients with Kaposi's sarcoma (KS) was evaluated in 22 consecutive, HAART-naïve KS patients attending a single Italian referral centre for HIV/AIDS. Clinical, virologic and immunologic responses to HAART were assessed at baseline and every three months during the follow-up. Peripheral blood mononuclear cell (PBMC)-associated human herpesvirus 8 (HHV-8) load was also evaluated by real-time PCR in 13 patients with durable clinical KS complete response (CR). In a median follow-up of 40 months (range 17-78), the KS overall clinical response rate was 91%: 18 complete and 2 partial responses were achieved, and two patients experienced disease progression. CR persisted in all 18 patients, including the 5 poor-risk KS patients in whom CR lasted for> 60 months, and was significantly linked to an increase in CD4+ cell counts and a drop in HIV-1-RNA copies. Compared to baseline levels, a decrease in PBMC HHV-8 load was observed at CR, and a significant further reduction was found at the end of follow-up. In this monocentric study, AIDS-KS patients treated with HAART showed high clinical response rate. Patients with CR showed a prolonged remission, lasting more than 5 years in a group of poor-risk patients, and a persistent reduction in circulating HHV-8-infected cells. These findings highlight that HAART deeply modifies the natural history of this tumour in AIDS patients, and that this long-lasting approach may be considered a first-line treatment for the majority of HIV-1-infected patients developing KS.