The route begins in the Golden Triangle of Pittsburgh as a limited-access highway, following the bank of the Allegheny and Ohio rivers around the Manchester neighborhood, passing north of Heinz Field and west of PNC Park. While limited-access, the road becomes "Ohio River Boulevard", named for the river that PA 65 parallels for between the city of Pittsburgh and the borough of Rochester. Outside of the city, the road becomes a four-lane at-grade roadway to Rochester, with some portions featuring a divided highway. North of Rochester, PA 65 narrows to two lanes and passes through predominantly rural land, running concurrent with PA 18 and PA 288 as it heads north.