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Background: While national adoption of universal HIV treatment guidelines has led to improved, timely uptake of antiretroviral therapy (ART), longer-term care outcomes are understudied. There is little data from real-world service delivery settings on patient attrition, viral load (VL) monitoring, and viral suppression (VS) at 24 and 36 months after HIV treatment initiation. Methods and findings: For this retrospective cohort analysis, we used observational data from 25 countries in the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium's Asia-Pacific, Central Africa, East Africa, Central/South America, and North America regions for patients who were ART naïve and aged ≥15 years at care enrollment between 24 months before and 12 months after national adoption of universal treatment guidelines, occurring 2012 to 2018. We estimated crude cumulative incidence of loss-to-clinic (CI-LTC) at 12, 24, and 36 months after enrollment among patients enrolling in care before and after guideline adoption using competing risks regression. Guideline change–associated hazard ratios of LTC at each time point after enrollment were estimated via cause-specific Cox proportional hazards regression models. Modified Poisson regression was used to estimate relative risks of retention, VL monitoring, and VS at 12, 24, and 36 months after ART initiation. There were 66,963 patients enrolling in HIV care at 109 clinics with ≥12 months of follow-up time after enrollment (46,484 [69.4%] enrolling before guideline adoption and 20,479 [30.6%] enrolling afterwards). More than half (54.9%) were females, and median age was 34 years (interquartile range [IQR]: 27 to 43). Mean follow-up time was 51 months (standard deviation: 17 months; range: 12, 110 months). Among patients enrolling before guideline adoption, crude CI-LTC was 23.8% (95% confidence interval [95% CI] 23.4, 24.2) at 12 months, 31.0% (95% CI [30.6, 31.5]) at 24 months, and 37.2% (95% [CI 36.8, 37.7]) at 36 months after enrollment. Adjusting for sex, age group, enrollment CD4, clinic location and type, and country income level, enrolling in care and initiating ART after guideline adoption was associated with increased hazard of LTC at 12 months (adjusted hazard ratio [aHR] 1.25 [95% CI 1.08, 1.44]; p = 0.003); 24 months (aHR 1.38 [95% CI 1.19, 1.59]; p <.001); and 36 months (aHR 1.34 [95% CI 1.18, 1.53], p <.001) compared with enrollment before guideline adoption, with no before–after differences among patients with no record of ART initiation by end of follow-up. Among patients retained after ART initiation, VL monitoring was low, with marginal improvements associated with guideline adoption only at 12 months after ART initiation. Among those with VL monitoring, VS was high at each time point among patients enrolling before guideline adoption (86.0% to 88.8%) and afterwards (86.2% to 90.3%), with no substantive difference associated with guideline adoption. Study limitations include lags in and potential underascertainment of care outcomes in real-world service delivery data and potential lack of generalizability beyond IeDEA sites and regions included in this analysis. Conclusions: In this study, adoption of universal HIV treatment guidelines was associated with lower retention after ART initiation out to 36 months of follow-up, with little change in VL monitoring or VS among retained patients. Monitoring long-term HIV care outcomes remains critical to identify and address causes of attrition and gaps in HIV care quality. Using real-world service delivery data, Ellen Brazier and team examine long-term HIV care outcomes under universal HIV treatment guidelines across 25 countries. Author summary: Why was this study done?: Although universal HIV treatment recommendations have been adopted in national HIV treatment guidelines, longer-term HIV care outcomes under such guidelines are poorly documented and largely limited to single-country studies with short follow-up times. No multicountry studies using real-world service delivery data have examined long-term HIV care outcomes associated under universal HIV treatment guidelines. What did the researchers do and find?: With data on 66,963 patients enrolling in HIV care at 109 clinics participating in the International epidemiology Databases to Evaluate AIDS (IeDEA) research consortium across 25 countries where universal HIV treatment guidelines were adopted, we estimated the hazard ratios of loss-to-clinic (LTC) at 12, 24, and 36 months after enrollment, comparing those enrolling in HIV care after guideline adoption to those enrolling before guideline adoption. Among 57,615 patients with documented initiation of antiretroviral therapy (ART), we also estimated the relative risks of clinic retention, viral load (VL) monitoring, and viral suppression (VS) at 12, 24, and 36 months after ART initiation, comparing those enrolling after versus before national adoption of universal treatment guidelines. Compared with patients enrolling in HIV care and initiating HIV treatment before national adoption of universal treatment guidelines, those enrolling and initiating treatment after guideline adoption had higher risk of being LTC at 12 months, 24 months, and 36 months after enrollment. Among patients retained in care after ART initiation, those enrolling in HIV care after the adoption of universal HIV treatment guidelines were more likely to have VL monitoring at 12 months after ART initiation and less likely at 36 months, with no difference at 24 months. VS was high at each time point among patients enrolling before and after the adoption of universal HIV treatment guidelines, with no substantive change associated with guideline adoption. What do these findings mean?: Our results raise concerns about long-term retention of patients after ART initiation, as well as the capacity of HIV programs to provide essential aspects of HIV care, including annual VL monitoring for timely identification of adherence problems and treatment failure. Our findings that patient retention in care at the clinic where ART was initiated decreased after the adoption of universal HIV treatment guidelines and that there has been no improvement in annual VL monitoring among patients retained in care should motivate efforts to identify and address factors associated with attrition among patients enrolling in HIV care, as well as barriers to routine VL testing in the era of universal treatment of all people living with HIV. Study limitations include potential underascertainment of patient outcomes in real-world service delivery data, lags in the availability of real-world service delivery data, and the nonrepresentativeness of the clinics and countries reflected in IeDEA datasets available for analysis. [ABSTRACT FROM AUTHOR]