Antiretroviral Therapy and Viral Suppression Among Active Duty Service Members with Incident HIV Infection — United States, January 2012–June 2018

Human immunodeficiency virus (HIV) infection is a deployment-limiting medical condition for U.S. armed forces in the Department of Defense (DoD) (1). HIV management using contemporary antiretroviral therapy (ART) regimens permits effective suppression of viremia among persons in clinical care. Although service members with HIV infection can remain in military service, treatment outcomes have not been fully described. Data from the Defense Medical Surveillance System (DMSS) were analyzed to estimate ART use and viral suppression among DoD service members with diagnosed HIV infection during January 2012–June 2018 (2). Among 1,050 service members newly diagnosed with HIV infection during January 1, 2012–December 31, 2017, 89.4% received ART within 6 months of HIV diagnosis, 95.4% within 12 months, and 98.7% by the end of the surveillance period on June 30, 2018. Analyses determined that, among 793 persons who initiated ART and remained in military service for ≥1 year, 93.8% received continuous ART, 99.0% achieved viral suppression within 1 year after ART initiation, and 96.8% were virally suppressed at receipt of their last viral load test. The DoD model of HIV care demonstrates that service members with HIV infection who remain in care receive timely ART and can achieve both early and sustained viral suppression.

DoD routinely screens its service members for HIV infection to ensure force health protection and to protect the battlefield blood supply (1). All active duty service members with HIV infection receive care through the Military Health System and can be retained in service if they can perform their duties. Clinical evaluations are performed by military infectious disease physicians following diagnosis of HIV infection and at least every 6 to 12 months thereafter.

Demographic information, military service personnel records, and laboratory data were extracted from the DMSS, which maintains longitudinal service-related and clinical surveillance data for all personnel throughout their military service. All cases of incident HIV infection occurring among active duty service members during January 1, 2012–December 31, 2017, were identified from surveillance data validated against HIV case lists maintained by each military service. Activated reservists and National Guard members were excluded because DMSS does not record accurate follow-up time for reserve or National Guard members. Pharmacy records for dispensed ART prescriptions were obtained from the DoD Pharmacy Data Transaction Service. This analysis was conducted by the Armed Forces Health Surveillance Branch as part of routine medical surveillance efforts on the health outcomes of service members living with HIV infection. Because the branch was conducting this analysis in its capacity as a public health authority providing medical surveillance support to DoD policymakers, institutional review board approval was not required.

ART initiation was assessed for 1,050 service members with incident HIV infection who remained in service for ≥6 months after diagnosis. ART initiation was defined as dispensation of an initial ART prescription during a specified time frame following diagnosis of HIV infection (within 6 months, within 12 months, or by the end of the study period).

Among 1,050 service members with incident HIV infection, 243 (23.1%) were excluded from analysis of continuous ART and viral suppression because of inadequate follow-up time (206; 19.6%) or incomplete viral load testing (37; 3.5%) and an additional 14 (1.3%) because ART history was missing, leaving 793 (75.5%) service members with incident HIV infection and at least 1 year of follow-up for analysis.* The 243 service members who initiated ART but were not included in additional analysis for continuous ART and viral suppression were similar demographically to the 793 who were included and had no evidence of being immunocompromised (median baseline CD4 count = 513 [interquartile range (IQR) = 386–659] cells/μL).

Continuous receipt of ART and viral suppression were assessed among the 793 persons who remained in service for at least 1 year after ART initiation and who had documented viral suppression within 6 months of ART initiation or a viral load test 6–12 months after ART initiation. Continuous ART was defined as dispensation of at least a 6 months’ supply of ART within 6 months of initiating ART. Viral suppression was defined as a viral load measurement of <200 copies of HIV RNA per mL within 1 year of ART initiation. Viral suppression was also reported at the last viral load test during follow-up 1 year after ART initiation and at the last viral load test of the surveillance period. In addition, viral suppression was calculated for each year of follow-up after HIV diagnosis, as the percentage of service members whose last viral load test during each year of follow-up was <200 copies of HIV RNA per mL, among service members with at least one viral load test during that follow-up year.

The median interval from diagnosis of HIV infection to the first viral load test indicating viral suppression was also calculated overall and stratified by year of HIV diagnosis. In addition, the overall median interval from HIV diagnosis to the last viral load test in the surveillance period was calculated. Median CD4 counts were calculated at baseline and at the last CD4 test during the surveillance period. SAS statistical software (version 9.4; SAS Institute) was used for all analyses.

Among 1,050 service members with incident HIV infection, 939 (89.4%) initiated ART within 6 months of diagnosis, 1,002 (95.4%) within 12 months, and 1,036 (98.7%) by the end of the surveillance period (Table 1). ART initiation within 6 months of diagnosis was more common among older service members, males, and those in the Air Force (Table 1). Initial ART regimens were anchored by integrase strand transfer inhibitors (63.0%), nonnucleoside reverse transcriptase inhibitors (28.2%), protease inhibitors (6.2%), or other combinations of these agents with or without nucleoside reverse transcriptase inhibitors (2.6%). After exclusion of the 243 service members with inadequate follow-up or viral load testing and the 14 with missing history of ART, among the remaining 793 service members, 744 (93.8%) received continuous ART, and 785 (99.0%) had at least one viral load result indicating viral suppression within 1 year after ART initiation (Table 2). Continuous receipt of ART was more prevalent among older service members, non-Hispanic whites, non-Hispanic blacks, males, officers, and pilot/aircrew personnel, compared with their respective counterparts. A high percentage of viral load suppression within 1 year after ART initiation (>96%) was achieved among all demographic subgroups. A total of 772 (97.4%) service members were virally suppressed at their last viral load test during follow-up 1 year after ART initiation and 768 (96.8%) were virally suppressed at their last viral load test of the surveillance period (Table 2). The percentage of service members with HIV infection who achieved viral suppression ranged from 91.6% of 787 persons in the first year of follow-up to 100% of 15 persons in the seventh year (Table 3). The interval from HIV diagnosis to first viral load test indicating viral suppression ranged from 6.9 months (IQR = 4.9–10.9) in 2012 to 2.9 months (IQR = 2.5–4.3) in 2017 (median = 4.6 months ([IQR = 2.9–7.2]). The median CD4 count at baseline was 486 cells/μL (IQR = 342–625) and 717 (IQR = 565–909) at the last test during the surveillance period.

Acknowledgments

Mildred Figueroa, Vanessa Miranda-Santiago, Navy Bloodborne Infection Management Center, Bethesda, Maryland; Elizabeth Bianchi, Rosemary Casimier, Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland; U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland; James Mancuso, Stephen Taubman, Armed Forces Health Surveillance Branch, Silver Spring, Maryland.

Corresponding author: Shauna Stahlman, shauna.stahlman.ctr@mail.mil, 301-319-3252.

¹Armed Forces Health Surveillance Branch, Silver Spring, Maryland; ²U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland; ³Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland; ⁴Emerging Infectious Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, Maryland; ⁵Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland; ⁶Office of Health Services Policy and Oversight, Office of the Assistant Secretary of Defense for Health Affairs, Falls Church, Virginia; ⁷Navy Bloodborne Infection Management Center, Bethesda, Maryland; ⁸Walter Reed National Military Medical Center, Bethesda, Maryland; ⁹Infectious Disease Service, San Antonio Military Medical Center, San Antonio, Texas.

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* Service members were required to have at least 6 months follow-up time after diagnosis of incident HIV infection.
^† All demographic and military characteristics ascertained at the time of incident HIV infection diagnosis.
^§ By June 30, 2018.

* Continuous ART was defined as having been dispensed at least 180 days’ supply of ART medications within 6 months of initiating ART.
^† Service members were required to have at least 1-year follow-up time after ART initiation. In addition, they must have been virally suppressed within 6 months of ART initiation or have a viral load test on file from 6 to 12 months after ART initiation.
^§ Viral suppression was defined as having a viral load <200 copies of HIV RNA per mL according to any viral load test that was performed within 1 year after ART initiation.
^¶ All demographic/military characteristics measured at the time of incident HIV diagnosis.

* Service members were required to have at least 1 year of follow-up after ART initiation and to have been virally suppressed within 6 months of ART initiation or have a viral load test on file from 6 to 12 months after ART initiation.
^† After diagnosis of HIV infection.
^§ Last viral load of each follow-up year <200 copies of HIV RNA per mL.
^¶ No. of persons who had a viral load test within 1 year of HIV diagnosis = 787 of 793.