Objective: To assess the prevalence of drug induced oral pigmentation among HIV-infected patients in Kodagu and evaluate its clinical characteristics. Methods: A total of 259 HIV patients receiving highly active antiretroviral therapy were included in this cross-sectional prospective study. Comprehensive mucocutaneous examinations were conducted, recording the site, extension, and duration of oral lesions following the initiation of antiretroviral treatment. The collected data were statistically analysed. Results: Among the study population, 168 patients (64.9%) were on TLE regimen, while 91 patients (35.1%) were on Zidovudine, Lamivudine, and Nevirapine regimen. Oral mucosal pigmentation was observed in 100 patients, and 14 patients exhibited both intraoral and extraoral pigmentation involving the skin, nails, and oral cavity. Conclusion: Prolonged treatment with highly active antiretroviral therapy is associated with drug-induced oral hyperpigmentation. Proper patient education regarding potential adverse reactions can help alleviate unnecessary concerns and improve adherence to the antiviral drug regimen.