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.