Background: People with HIV (PWH) may experience accelerated aging, chronic inflammation, early immunosenescence, and increased vulnerability to pneumonia. However, data on pneumonia outcomes in older PWH compared with people without HIV remain limited.

Methods: We conducted a retrospective analysis of prospectively collected data from November 1996 through March 2025, including adults hospitalized with community-acquired pneumonia (CAP). The primary endpoint was 30-day mortality; secondary outcomes included in-hospital and 1-year mortality, intensive care unit (ICU) admission, hospital and ICU length of stay, ICU mortality, and mechanical ventilation. Propensity score matching (PSM) was used to balance baseline characteristics between groups.

Results: Among 5404 patients with CAP, 5306 (98%) were HIV negative and 98 (2%) were PWH. In the unmatched cohort, PWH were younger, more likely to be smokers, and more likely to report alcohol misuse; they also had more comorbidities and prior pneumonia. Despite milder initial clinical features and lower inflammatory marker levels, PWH had longer ICU stays. HIV status was not associated with ICU admission or 30-day or 1-year mortality in crude analyses. After PSM (96 PWH vs 96 HIV-negative patients), baseline differences were minimized, and no significant differences in outcomes were observed: ICU admission, 21% vs 25% (OR, 0.78; 95%CI, 0.40-1.55); 30-day mortality, 8% vs 3% (HR, 2.76; 95%CI, 0.73-10.39); and 1-year mortality, 12% vs 7% (HR, 2.60; 95%CI, 0.82-8.29).

Conclusions: In this single-center cohort of adults aged ≥50 years hospitalized with CAP, we did not demonstrate a statistically significant association between HIV infection and mortality after propensity score matching. However, the limited sample size and wide confidence intervals reduce statistical precision, and clinically relevant differences cannot be excluded.