Older people living with HIV (PLWH) may have delayed diagnosis and access to care and therefore have poorer disease outcomes. Little is known about HIV care and disease outcomes among older PLWH in China. This retrospective cohort study used data from all adult HIV/AIDS cases during 1988–2017 in Chongqing, China from two national databases. We compared demographic and behavioral profiles, HIV care, virologic suppression, and mortality between two age groups of 18–49 and ≥50 years. Multivariate logistic and cox regression analyses were used to calculate adjusted odds ratio (AOR) and adjusted hazard ratio (AHR) among older versus younger PLWH. Of 46,580 adult HIV/AIDS cases, 76.1% were men and 38.2% were 50 years of age or older. The proportion of older cases in men increased from 2.4% in 2002 to 51.8% in 2017, and in women from 3.3% to 57.9%. Older PLWH had a lower CD4 count than their younger counterparts at HIV diagnosis (median 323 vs. 391 cells/μL; p < .001). The average time from HIV diagnosis to initiation of antiretroviral therapy (ART) were 6.3 months among older and 12.8 months among younger PLWH ( p < .001). Nearly one tenth (9.6%) had virologic failure within 12 months of ART initiation, and the odds of virologic failure among older PLWH was 80% higher [AOR 1.8; 95% confidence interval (CI), 1.1–3.0] than among younger ones after controlling for calendar year of initiating ART and other covariates. The mortality rate within 12 months of initiating ART was 9.8 deaths per 100 person years, and the risk of mortality among older PLWH was three times among younger ones (AHR, 3.1; 95% CI, 2.1–4.6). Older people represented an increasing proportion of new HIV/AIDS cases and were more likely to have virologic failure and mortality within 12 months of ART initiation.