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HAART Outcomes in the TACC HIV Natural History Study: A Model for Universal Access to Health Care in the United States
Vincent Marconi*1,2, G Grandits1,3, A Weintrob1,4, M Landrum1,2, N Crum-Cianflone1,5, A Ganesan1,6, B Hale1,5, S Wegner1, B Agan1, and M Dolan2
1Infectious Disease Clinical Res Prgm, Uniformed Svcs Univ of the Hlth Sci, Bethesda, MD, US; 2San Antonio Military Med Ctr, Fort Sam Houston, TX, US; 3Coordinating Ctr for Biometric Res, Univ of Minnesota, Minneapolis, US; 4Walter Reed Army Med Ctr, Washington, DC, US; 5Naval Med Ctr, San Diego, CA, US; and 6Natl Naval Med Ctr, Bethesda, MD, US
Background: The success of HAART for HIV depends
upon access and adherence to potent combination therapy and close monitoring. We
examine the virologic, immunologic, and clinical outcomes of HAART in a US military cohort which has free access to health care and requisite follow-up for active
duty personnel to determine risk factors for treatment failure under these
circumstances.
Methods: For this study, 2352 subjects in the US
Military HIV Natural History Study, who initiated HAART between 1996 and 2008,
were followed for a median of 5 years (IQR 2 to 10 years) for virologic
response, CD4 count changes, AIDS events, and mortality. Virologic failure was
defined as never having virologic suppression (viral load < 400 copies/mL)
or having ≥2 consecutive detectable viral loads (viral load ≥400 copies/mL)
after virologic suppression. Multivariate analyses were performed to identify
risk factors associated with these outcomes. Analyses were stratified by era of
HAART initiation (before or after 2000).
Results: Characteristics for those who started HAART
in the cohort were as follows: mean age 35, 91% males, 56% on active duty, log
viral load at HAART start 4.3, CD4 count at HAART 343 cells/mL, 12% prior AIDS,
52% prior ART, 69% PI use. Among subjects who started in the late HAART era,
81% had virologic suppression at 1 year, 85% at 5 years, and 82% at 8 years. At
5 years, 34% experienced virologic failure and the median CD4 increase was 247
cells/mL. AIDS events and mortality rates were 2% and 0.3%, respectively. In
the multivariate analyses model that adjusted for age, gender, ethnicity, year
of diagnosis, regimen, hepatitis co-infection, sexually transmitted diseases,
baseline viral load, CD4 count and hemoglobin, prior AIDS events and ARV use,
being on active duty was associated with a decreased risk of AIDS (HR 0.6, 0.4
to 1.0) and mortality (0.6, 0.3 to 0.9) and an increased probability of CD4
increase >30% (1.3, 1.1 to 1.4).
Conclusions: In this cohort with access to free
healthcare for all subjects and regular follow up, the rates of virologic
suppression exceed that seen in many clinical cohorts. Active duty status
appears to be instrumental in HAART outcomes after adjusting for known risk
factors. These findings support the notion that free access to care likely
improves virologic response to HAART thereby reducing HIV-related morbidity and
mortality. Being on active duty might serve as a surrogate for better health or
improved access to care, suggesting that there may be a benefit to initiating
HAART under these conditions.
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