Pulmonary diseases remain the most common complication associated with high morbidity and mortality in patients with human immunodeficiency virus (HIV) infection. Invasive diagnostic procedures are often needed to establish a specific diagnosis of pulmonary disease. We report our experience with ultrasound (US)-guided percutaneous transthoracic needle aspiration (PTNA) biopsy in 20 consecutive patients with advanced HIV infection who presented with a variety of pulmonary lesions with or without pleural effusion. A specific diagnosis was established in 16 patients (80%), with infection being the most common etiology. Sputum culture yielded the same causative pathogen in three patients (15%) and all had more than one bacterial or fungal isolates. Mild pneumothorax, the only complication, was observed in two patients (10%) following the procedure. Neither patient required chest tube drainage. Our findings suggest that US-guided PTNA can be a useful and safe alternative to fluoroscopy-guided PTNA in selected HIV-infected patients with focal pulmonary lesions and pleural effusion.