In 2024, 40.8 million people were living with HIV, with 1.3 million new infections and 630,000 deaths. Despite access to antiretroviral therapy, cases with CD4 < 200 cells/mm³ persist, favoring AIDS-defining illnesses. Non-communicable chronic diseases have increasingly contributed to morbidity and mortality in developed countries. In Brazil, there are few recent data on causes of death among people living with HIV (PLHIV). This study describes causes of death among PLHIV hospitalized between 2018 and 2024 in a university hospital.

Retrospective study of medical records of patients ≥ 18 years old with advanced HIV disease who died.

Median age at death was 48 years (20–85); 71.3% were male at birth. Gender identity was not recorded for 97.39%; 1.73% were transgender women; 0.87% cisgender men. Schooling: incomplete elementary school (26.3%), completed high school (26.3%), unknown (14.9%). Ethnicity: white (55.65%), mixed race (31.3%), Black (9.56%), Asian (1.74%), unknown (1.74%). Comorbidities included smoking (39.1%), chronic kidney disease (37.4%), alcohol use (30.4%), hypertension (20.9%), diabetes (17.4%) and 13.04% were on oncologic immunosuppressive therapy. HIV transmission routes: sexual (85.2%), injectable drugs (8.7%), vertical (2.6%), and transfusion (0.9%). Most frequently prescribed antiretrovirals were lamivudine (69.6%), dolutegravir (60.9%), tenofovir (52.2%), with occasional protease inhibitor use. Delay in antiretroviral pickup: median 301 days (102–936), with 10.43% not picking up medications. Care-related factors associated with death were loss to follow-up (30.4%), late diagnosis (21.7%), virologic failure (19.3%), and undetectable viral load with adherence (29.6%). AIDS-defining illnesses: cytomegalovirus disease (26.1%), pneumocystosis (24.3%), and pulmonary tuberculosis (21.7%). CD4 nadir: median 60 cells/mm³ (1–1,233). Last CD4 before hospitalization: median 163 cells/mm³ (3–1,275; 20% without records). Last viral load: median 22,211 copies/mL; 33.04% undetectable. Hospitalization: median 12 days (1–208). The underlying cause of death was AIDS-related in 79.1% of cases across age groups: 21–40 years (30.8%), 41–60 years (45.1%) and > 60 years (23.1%). Respiratory causes accounted for 6.1% of deaths; among these, 57.1% occurred in those aged 41–60 years, 28.6% in > 60 years, and 14.3% in 21–40 years. Hepatic causes represented 4.3% of total deaths, occurring in ages 21–40 years (40%) and 41–60 years (60%).

AIDS remains the main cause of death, but chronic conditions are increasingly relevant, especially among older individuals.