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Objectives  To assess long‐term antiretroviral therapy ( ART ) outcomes during rapid  HIV  programme expansion in the public sector of Eswatini (formerly Swaziland).    Methods  This is a retrospectively established cohort of  HIV ‐positive adults (≥16 years) who started first‐line  ART  in 25 health facilities in Shiselweni (Eswatini) between 01/2006 and 12/2014. Temporal trends in  ART  attrition, treatment expansion and  ART  coverage were described over 9 years. We used flexible parametric survival models to assess the relationship between time to  ART  attrition and covariates.    Results  Of 24 772  ART  initiations, 6% ( n  = 1488) occurred in 2006,  vs . 13% ( n  = 3192) in 2014. Between these years, median  CD 4 cell count at  ART  initiation increased (113–265 cells/mm 3 ). The active treatment cohort expanded 8.4‐fold,  ART  coverage increased 8.0‐fold (7.1% in 2006  vs . 56.8% in 2014) and 12‐month crude  ART  retention improved from 71% to 86%. Compared with the pre‐decentralisation period (2006–2007), attrition decreased by 5% (adjusted hazard ratio [ aHR ] 0.95, 95% confidence interval 0.88–1.02) during  HIV ‐ TB  service decentralisation (2008–2010), by 17% ( aHR  0.83, 0.75–0.92) during service consolidation (2011–2012), and by 20% ( aHR  0.80, 0.71–0.90) during further treatment expansion (2013–2014). The risk of attrition was higher for young age, male sex, pathological baseline haemoglobin and biochemistry results, more toxic drug regimens,  WHO III / IV  staging and low  CD 4 cell count; access to a telephone was protective.    Conclusions  Programmatic outcomes improved during large expansion of the treatment cohort and increased  ART  coverage. Changes in  ART  programming may have contributed to better outcomes.

tropical medicine and international health

Programmatic outcomes and impact of rapid public sector antiretroviral therapy expansion in adults prior to introduction of the WHO treat‐all approach in rural Eswatini