Ten-year outcomes of antiretroviral therapy : a retrospective cohort study in Tshwane district, South Africa

Abstract

BACKGROUND : South Africa continues to face one of the world’s highest HIV burdens, with 7.7 million people living with HIV (PLWHIV) in 2023. Despite progress toward UNAIDS 95–95–95 targets, challenges in long-term retention and treatment outcomes persist. This study aimed to evaluate 10-year antiretroviral therapy (ART) outcomes among PLWHIV initiated on treatment in 2013 within Tshwane District, South Africa. METHODS : Retrospective cohort using Tier.Net data from 1,337 adults across 10 randomly selected facilities (clinics and community health centres [CHCs]). Outcomes were retention, loss to follow‑up (LTFU), mortality, viral suppression, and CD4 recovery. We used Kaplan–Meier methods and multivariable models (Cox for LTFU and mortality, logistic for viral suppression, linear for CD4 change). Mortality analyses were limited to participants with complete ascertainment (n = 640). RESULTS : At 10 years, 47.7% were retained, 30.4% LTFU, 20.1% transferred out, and 3.3% died. Attrition was steepest early and most pronounced among 18–24-year-olds. Advanced WHO stage strongly predicted death (Stage III/IV vs. I/II: aHR 3.06, 95% CI 1.26–7.44), and younger age was protective (≤ 34 vs. > 34 years: aHR 0.28, 95% CI 0.09–0.86). Care at CHCs was associated with lower mortality (aHR 0.33, 95% CI 0.13–0.83) and greater CD4 gains (clinic care: −74.35 cells/µL vs. CHCs; p < 0.001). Female sex was associated with larger CD4 recovery (+ 90.06 cells/µL vs. males; p < 0.001). Only baseline CD4 > 200 cells/µL independently predicted viral suppression (aOR for being suppressed ≈ 1.89, derived from aOR 0.53 for non-suppression; p < 0.001). No baseline covariates were significant predictors of time to LTFU (clinic type borderline: HR 0.80, p = 0.086). CONCLUSION : A decade after initiation, fewer than half remained in care. Mortality clustered among older adults and those presenting with advanced disease, while CHC-based care conferred survival and immunologic advantages. Programme priorities should include earlier diagnosis and ART start, youth-friendly retention strategies, and scaling CHC-style differentiated service delivery to improve long-term outcomes.