Pragmatic Strategies for Sustaining HIV Care: 25-Year Outcomes from an Independent Practice in India.

BackgroundLong-term evidence from resource-limited settings spanning transitions in HIV care is scarce. We describe 25-year outcomes from a pragmatic Indian cohort employing simplified regimens and strategic drug sequencing.MethodsTreatment-naïve adults initiated dual-nucleoside reverse transcriptase inhibitor therapy (2000-2025), reserving protease and integrase inhibitors for later lines ("class preservation"). Primary outcomes were survival and treatment durability.ResultsAmong 971 patients retained in care (12,438 patient-years), Kaplan-Meier survival was 95.8% at 5 years and 88.3% at 25 years. Median first-line durability was 8.3 years. Overall, 85% achieved ≥95% adherence. Opportunistic infection incidence declined from 451.5 to 69.7 per 1000 patient-years. Clinically driven monitoring saved US$7578 per patient.ConclusionsFor patients retained in continuous care, strategic sequencing, intensive adherence support, and provider continuity sustained durable outcomes over 25 years. These findings characterize outcomes achievable under sustained engagement rather than population-level results.